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Sheboygan Senior Community Inc

3505 County Road Y, Sheboygan, WI 53083 · Non profit - Corporation · 60 certified beds · (920) 458-2137 Medicare & Medicaid certified

Call the home — (920) 458-2137 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Feb 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4000 Enterprise Dr · (920) 459-9090 · Call to confirm hours
Pharmacy
4433 Vanguard Dr · (920) 459-9470 · Call to confirm hours
Grocery
4811 Venture Dr · (920) 565-6328 · Call to confirm hours
Park
3911 County Road Y · (920) 451-2320 · Typically dawn to dusk
Place of worship
4204 Hunters Glen Dr · (920) 619-8556

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased30.2%16.1%15.4%worse
Long-stay residents who lose too much weight5.8%5.1%5.4%typical
Long-stay residents with a catheter left in their bladder4.1%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection6.6%2.7%2.0%worse
Long-stay residents with depressive symptoms3.8%5.7%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.5%3.3%3.3%better
Long-stay residents whose ability to walk worsened47.4%18.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.8%16.9%18.9%worse
Long-stay residents given the seasonal flu vaccine92.6%95.0%95.3%typical
Long-stay residents with pressure ulcers7.3%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control19.2%24.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.3%15.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.6%82.2%79.4%typical
Short-stay residents rehospitalized after admission18.3%23.1%22.6%better
Short-stay residents with an outpatient ER visit6.2%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days3.581.661.67worse
Long-stay outpatient ER visits per 1,000 resident days1.712.291.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 71 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.6%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
76.2%U.S. median 56.6%
Met the expected recovery
0.10U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
<0.01hours / resident / day
Occupational therapy

Met the expected recovery: 76.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.6%CMS range 48.7–67.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.9–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge76.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge66.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified67.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge92.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 3.4–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.701.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.29
RN hours/ resident / day
0.94
LPN hours/ resident / day
3.03
Aide hours/ resident / day
4.26
Total nurse hours/ resident / day
0.11
RN hoursweekends
36.8%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 60 beds and averages 55.6 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.03 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.04 hrs/resident/day on weekends vs 4.34 on weekdays — 7% thinner on weekends. RN hours go from 0.36 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-01-20)
15
at the previous standard inspection (2024-09-25)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2026-01-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure care was provided in accordance with a physician order for 1 resident (R) (R9) of 16 sampled residents.R9 had a diabetic heel ulcer. An Apligraf (a bioengineered, bi-layered skin substitute that contains living human keratinocytes, fibroblasts, and bovine collagen commonly used to treat diabetic foot ulcers) was applied at a podiatry appointment on 11/3/25 with an order not to remove the graft. Staff removed the graft on 11/4/25 and did not inform the podiatry clinic. During a podiatry appointment on 11/11/25, it was noted that the Apligraf was missing and R9's ulcer had worsened. R9 was hospitalized for nine days and diagnosed with osteomyelitis (a bone infection). R9 required surgical debridement and both intravenous (IV) and oral antibiotics. The facility's lack of order entry process along with not following current orders/not clarifying orders with the physician resulted in the Apligraf being removed between 11/3/25 and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 57 residents residing in the facility. The microwaves on all three households contained dried food debris. Food items in the dry storage area were not label with use-by dates. Equipment in the main kitchen was not stored to prevent contamination. Findings include: On 1/13/26 at 2:09 PM, Surveyor interviewed Dietary Manager (DM)-R who stated the facility follows the Wisconsin Food Code. Microwave Cleanliness: The Wisconsin Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Wisconsin Food Code documents…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 3 residents (R) (R36, R37 and R63) of 5 sampled residents reviewed for unnecessary medication had documentation that indicated the resident and/or their legal representative were thoroughly informed of the risks and benefits of prescribed psychotropic medication. R36 was prescribed duloxetine (antidepressant medication). The facility did not ensure an Informed Consent for Medication form was thoroughly reviewed and completed with R36. R37 was prescribed lorazepam (antianxiety medication) and desipramine (antidepressant medication). The facility did not ensure Informed Consent for Medication forms were thoroughly reviewed and completed with R37. R63 was prescribed buspirone (antianxiety medication) and citalopram (antidepressant medication). The facility did not ensure Informed Consent for Medication forms were thoroughly reviewed and completed with R63. Findings include: The facility's undated Psychotropic Medication policy indicates: .1.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not notify the State Long-Term Care Ombudsman of an emergent hospital transfer for 1 resident (R) (R10) of 6 sampled residents.R10 was transferred to the Emergency Department (ED) on 11/25/25 for evaluation. The Ombudsman was not notified of the transfer. In addition, Social Worker (SW)-L was not aware of the need to notify the Ombudsman of hospital transfers if the resident returned to the facility.Findings include:The facility's undated Discharge policy did not include Ombudsman notification of hospital transfers.From 1/12/26 to 1/15/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus and peripheral artery disease. R10's Minimum Data Set (MDS) assessment, dated 1/5/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 had intact cognition.R10's medical record indicated R10 was transferred to the ED on 11/25/25 for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 3 residents (R) (R36, R1, and R28) of 16 sampled residents.R36's MDS assessments, dated 1/2/26 and 12/3/25, indicated R36 received hypnotic medication. R36 was not prescribed a hypnotic medication.R1's MDS assessment, dated 10/13/25, indicated R1 received parenteral feeding. R1 did not receive parenteral feeding. R28's MDS assessment, dated 11/20/25, did not indicate R28 was on dialysis. R28 was on dialysis since admission to the facility on 8/14/25. Findings include: The facility's Minimum Data Set (MDS)/Health Information Process policy, dated September 2025, indicates: .3. (Named Company) will upload all relevant information including the resident's history and physical, hospital discharge summary, medical visits, imaging, and labs. (Named Company) completes authorizations, updates, audits, and coding .6. Section K is completed by the Registered Dietitian .8. Sections H,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure care and services to prevent pressure injuries from developing and/or promote healing was provided for 2 residents (R) (R8 and R36) of 6 sampled residents.On 11/20/25, R8 was noted to have a stage 1 pressure injury on top of the head. The facility did not ensure preventative measures were implemented to prevent further skin breakdown which resulted in a stage 2 pressure injury on top of R8's head.On 12/26/25, R36 was re-admitted to the facility from an acute hospital stay with a stage 2 pressure injury on the left buttock. On 1/3/26, the facility documented that R36 developed a stage 2 pressure injury on the right buttock. The facility did not ensure initial evaluations and/or wound assessments were completed to monitor R36's pressure injuries.Findings include:The facility's undated Pressure Injuries Overview/Staging policy indicates avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not complete a fall report to determine the root cause of a fall, update a care plan, or implement post-fall monitoring for 1 resident (R) (R8) of 1 sampled resident. R8 had an unwitnessed fall on 1/8/26. The facility did not complete a fall incident report or post-fall neurological checks. In addition, the facility did not update R8's care plan with a preventative safety intervention.Findings include:The facility's undated Assessing Falls policy indicates: .6. Observe for delayed complications of a fall for approximately seventy-two hours after a fall and document findings in the medical record .8. Complete an incident report for a resident fall no later than 24 hours after the fall occurs. The incident report should be completed by the nursing supervisor on duty and submitted to the Director of Nursing (DON) .When a resident falls, the following information should be recorded in the resident's medical record . 2. Assessment data, including vital…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 3 residents (R) (R10, R15, and R62) of 3 sampled residents.R10, R15, and R62 did not have orders or care plans for nebulizer (a medical device that turns liquid medicine into a fine mist allowing it to be inhaled directly into the lungs to treat respiratory conditions) cleaning.Findings include:The facility's undated Administering Medications Through a Small Volume Nebulizer policy indicates: .Steps in the Procedure: .26. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; d. Rinse all pieces with sterile water (not tap, bottled, or distilled); and e. Allow to air dry on a paper towel .28. When equipment is completely dry, store in a plastic bag with the resident's name and date.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure vital signs, weight, and monitoring of the fistula site were completed before and after dialysis for 1 resident (R) (R28) of 1 sampled resident.R28's medical record did not contain orders to obtain vital signs or weight or monitor the fistula site pre- or post-dialysis. Findings include: The facility's Dialysis policy, dated October 2025, indicates: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan .to meet the medical needs of the resident receiving hemodialysis .Compliance Guidelines: .4. The licensed nurse will communicate to the dialysis facility via .dialysis communication form or other form, that will include but not limit itself to: .b. Vital signs .d. Nutritional/fluid management including documentation of weights .7. The nurse will monitor and document the status of the resident's access site upon…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 2 residents (R) (R4 and R6) of 7 sampled residents. On 11/22/24, R7 notified staff that R1 was physically aggressive toward R4 on 11/21/24. The facility did not report the allegation of abuse to the SA. On 11/22/24, R1 initiated a resident-to-resident altercation with R6. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Exploitation policy, revised 5/2023, indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents .Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 2 residents (R) (R4 and R6) of 7 sampled residents. On 11/22/24, R7 notified staff that R1 was physically aggressive toward R4 on 11/21/24. The facility did not thoroughly investigate the allegation of abuse. On 11/22/24, R1 was physically aggressive toward R6. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Exploitation policy, revised 5/2023, indicates: The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident .A root cause investigation and analysis will be completed. A thorough investigation is an investigation that adequately addresses the circumstances of the allegation. The investigation will include the facts necessary…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · F2024-09-25 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interview and record review, the facility did not ensure the individual designated as the food and nutritional services director met the minimum qualifications for the role. This had the potential to affect all 55 residents residing in the facility. Dietary Manager (DM)-H did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 9/23/24 at 9:04 AM, Surveyor interviewed DM-H who indicated DM-H worked in the facility for several years and had been the Dietary Manager for 3 to 4 years. DM-H indicated DM-H was ServSafe certified; however, DM-H's certification expired in August and DM-H had not renewed it. DM-H indicated DM-H was not currently enrolled in a dietary or food service manager certification course. On 9/24/24 at 3:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed DM-H was not certified or enrolled in a certified training program. NHA-A stated it was not in the facility's budget to get DM-H certified.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 54 of 55 residents residing in the facility. Cooling temperature logs were not completed for leftover and pre-made food. Staff did not consistently monitor or document cooked food temperatures or hot/cold holding temperatures. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Staff did not monitor and document dishwasher and surface temperatures. Staff did not follow procedures for reheating food in a microwave. Staff did not wear hair restraints when entering the kitchen where resident food was prepared. Staff did not perform appropriate hand hygiene and safe food handling practices when serving food. Findings include: On 9/23/24 at 9:04 AM, Surveyor completed an initial tour of the kitchen with Dietary Manager (DM)-H who stated the facility followed the Federal Food Code. Cooling Temperatures: The 2022 Federal Food…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-25 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not ensure minimum required members of the Quality Assessment and Assurance (QAA) committee met at least quarterly. The facility did not have documentation that indicated the minimum required members of the QAA committee met at least quarterly. As of 9/25/24, the facility's most recent QAA committee meeting with all required members in attendance was on 6/12/23. Findings include: On 9/24/24, Surveyor requested the facility's policy and procedure for Quality Assurance and Performance Improvement (QAPI). Director of Nursing (DON)-B provided Surveyor with an undated QAPI Plan which was worded in the style of a template and did not describe the facility's specific QAPI policy and procedure. The QAPI Plan did not designate staff (including the DON, Medical Director or designee, the Infection Preventionist, and at least 3 other staff members one of whom was the Nursing Home Administrator (NHA), owner, board member, or other individual in a leadership role) required to participate in the QAPI committee and did not establish the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-25 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable disease and infection. This practice had the potential to affect all 55 residents residing in the facility. The facility did not appropriately monitor residents and staff for infections and outbreaks. Findings include: The facility's Surveillance for Infections policy, dated 9/2017, indicates: The Infection Preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiological significant organisms and HAIs to guide appropriate interventions and prevent future infections .4. For targeted surveillance using facility-created tools, follow…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-25 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 55 residents residing in the facility. Director of Nursing (DON)-B and Registered Nurse (RN)-E were the facility's designated IPs and did not complete specialized training in infection prevention and control. Findings include: The facility's Infection Preventionist policy, dated 9/2017, indicates: The IP is responsible for coordinating the implementation and updating of the infection control program. Qualifications: 1. The IP is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role 2. The IP remains current with infection prevention and control issues and is aware of national organizations guidelines as well as those from national/state/local and public health authorities. 3. Evidence of training is provided through a certificate(s) of completion or equivalent documentation. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-25 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and resident and staff interview, the facility did not maintain the dignity of 3 residents (R) (R18, R23, and R50) in the dining room during meal time with the potential to affect more than 4 of 55 residents residing in the facility. R18's vital signs were obtained at the dining table during the lunch meal on 9/24/24. Medications were administered to residents at the dining table, including R23. Residents who sat at the same table were not served at the same time, including R50. Findings include: On 9/23/24 at 11:49 AM, Surveyor observed lunch service in the Oak dining room. There were thirteen residents in the dining room. Surveyor witnessed the following: ~ On 9/23/24 at 11:49 AM, staff obtained R18's blood pressure at the table with other residents present. Dining service had already started. ~ On 9/23/24 at 11:57 AM, staff administered medication to multiple residents while eating, including R23. ~ On 9/23/24 at 12:10 PM, four residents were served and 9 residents were without food. ~ On 9/23/24 at 12:35 PM, the last resident's food was served. All residents…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-25 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure 4 residents (R) (R17, R45, R46, and R6) of 5 sampled residents who received psychotropic medication were monitored for adverse reactions or side effects of the medication. R17 was prescribed lorazepam (an antianxiety medication), sertraline (an antidepressant medication), and quetiapine (Seroquel) (an antipsychotic medication). R17's plan of care did not indicate R17 was monitored for adverse reactions or side effects of the medications. R45 was prescribed Seroquel. R45's plan of care did not indicate R45 was monitored for adverse reactions or side effects of the medication. R46 was prescribed lorazepam, sertraline, and quetiapine (Seroquel). R46's plan of care did not indicate R46 was monitored for adverse reactions or side effects of the medications. R6 was prescribed lorazepam, sertraline, and mirtazapine (an antidepressant medication also used for appetite). R6's plan of care did not indicate R6 was monitored for adverse reactions or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview, and record review, the facility did not ensure 1 resident (R) (R31) of 18 sampled residents and their activated Power of Attorney (POA) were offered care conferences and involved in continued care planning. R31's only care conference was completed on 9/17/21. Social Worker (SW)-C verified care conferences should be held yearly, when there is a change in a resident's condition, or if requested by a resident's family. Findings include: On 9/23/24, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), epilepsy, and cognitive communication deficit. R31's Minimum Data Set (MDS) assessment, dated 7/31/24, indicated R31 had severely impaired cognition. R31 had an activated POA. R31's medical record did not indicate care conferences were offered or declined by R31's POA. On 9/23/24 at 11:58 AM, Surveyor interviewed R31's POA who indicated they were not involved with R31's plan of care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not ensure 1 resident (R) (R109) of 3 sampled residents signed and received a copy of the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which is used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility), and standard claim appeal rights and instructions. The facility did not provide an ABN form (a document that explains financial liability, including the facility's daily rate for services) to R109 when R109's Medicare benefits ended on 5/16/24 and R109 remained in the facility. Findings include: The Centers for Medicare & Medicaid Services (CMS)-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends to continue services and the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure 3 residents (R) (R1, R19 and R32) of 5 sampled residents received a written transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R1 was transferred to the hospital on 8/7/24. Neither R1 or R1's Power of Attorney (POA) were provided with a written transfer notice. R19 was transferred to the hospital on 8/17/24. Neither R19 or R19's POA were provided with a written transfer notice. R32 was transferred to the hospital on 2/20/24. Neither R32 or R32's POA were provided with a written transfer notice. Findings include: The facility's Transfers and Discharges policy, dated 2/11/22, indicates: Involuntary Removal: 1. The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility .Residents will be transferred or discharged from Sheboygan Senior Community (SSC) only for medical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure 3 residents (R) (R1, R19, and R32) of 4 sampled residents reviewed for hospitalization received written information on the duration of the bed-hold policy, the reserve bed payment policy, and the right to return to the facility. R1 was transferred to the hospital on 8/7/24. Neither R1 or R1's activated Power of Attorney (POA) were provided with a written bed-hold notice. R19 was transferred to the hospital on 8/17/24. Neither R19 or R19's POA were provided with a written bed-hold notice. R32 was transferred to the hospital on 2/20/24. Neither R32 nor R32's POA were provided with a written bed-hold notice. Findings include: The facility's Bed Hold, readmission or Return to the Facility policy, dated 2/11/22, indicates: The facility shall inform and provide in writing to the resident and/or the resident's representative the facility's bed hold and return to the facility policy at the time of transfer .specifying the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the care plan was reviewed and revised as needed for 1 resident (R) (R32) of 18 sampled residents. R32 had new diagnoses of cerebrovascular accident (CVA) (stroke) and Parkinson's disease. The facility did not revise R32's care plan to address R32's new diagnoses. Findings include: From 9/23/24 to 9/25/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease (CKD), and dementia. R32's Minimum Data Set (MDS) assessment, dated 2/29/24, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney (POA). R32's medical record indicated R32 was admitted to the hospital on [DATE] for a CVA and was re-admitted to the facility on [DATE]. A progress note, dated 3/28/24, indicated R32 had a new diagnosis of Parkinson's disease. R32's care plan did not address…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R19) of 19 sampled residents received the necessary care and services to prevent or monitor weight loss. R19 had an order for weekly weights which were not consistently obtained and documented. In addition, R19 experienced a severe weight loss and the appropriate follow-up was not completed. Findings include: The facility's Weighing and Measuring the Resident policy, with a revised date of 3/2011, indicates: The purpose of this procedure is to determine the resident's weight and height, provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and provide a baseline height in order to determine the ideal weight of the resident .4. Weight is usually measured upon admission and monthly during the resident's stay .1. Report significant weight loss/gain to the nurse supervisor. 2. The threshold for significant unplanned and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R208) of 5 sampled residents was monitored for adverse reactions or side effects of a high-risk medication. R208 was prescribed clopidogrel (an anticoagulant medication). R208's care plan did not contain monitoring interventions for adverse reactions or side effects of the high-risk medication. Findings include: According to medlineplus.gov, clopidogrel may cause side effects including, but not limited to: Excessive tiredness, dizziness, nausea, vomiting, stomach pain, diarrhea, nosebleed, hives, rash, itching, difficulty breathing or swallowing, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, black and tarry stools, red blood in stools, bloody vomit, vomit that looks like coffee grounds, unusual, bleeding or bruising, pink or brown urine, slow or difficult speech, weakness or numbness of an arm or a leg, changes in vision, shortness of breath, purple patches or bleeding under the skin,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0840 — isolated
    Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not acquire a current contract/agreement in writing for outside dialysis services for 1 resident (R) (R360) of 1 resident reviewed for dialysis services. R360's physician orders indicated R360 received dialysis three times per week. The facility did not have a current contract or agreement with the dialysis provider. The facility also did not have a policy related to dialysis treatment. Findings include: On 9/24/24, Surveyor reviewed R360's medical record. R360 was admitted to the facility on [DATE] with diagnoses including hypertensive chronic heart and kidney disease with stage 5 renal disease. R360 received hemodialysis three times weekly. On 9/24/24 at 11:15 AM, Surveyor requested the dialysis contract/agreement from Health Services Specialist (HSS)-F for R360's renal dialysis. HSS-F indicated the facility did not have a contract with the dialysis center. When Surveyor requested a policy and procedure for dialysis, HSS-F indicated the facility did…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-07-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 57 residents residing in the facility. In addition, facility did not have a system to monitor staff illness, symptoms, and return to work dates. The facility did not have a system to prevent the growth and spread of Legionella in the facility's water system. The facility did not monitor staff illness, including onset of symptoms, end of symptoms and return to work dates. Findings include: 1. The 7/6/18 revised Centers for Medicaid and Medicare Services (CMS) Quality, Safety and Oversight Letter 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) contains the following information: Facilities must have water management plans and documentation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an as needed (PRN) psychotropic medication was not utilized more than 14 days unless an alternate duration with rationale was provided for 1 Resident (R) (R45) of 5 residents reviewed for unnecessary medication. The facility did not discontinue R45's PRN Lorazepam (an anti-anxiety medication) order after 14 days or obtain an alternate duration with rationale. Findings include: The facility's Psychotropic Medication Use policy, dated 7/22, contained the following information: PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. From 7/17/23 through 7/19/23, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] with diagnoses that included…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BANK FIRST NATIONALOrganization5% OR GREATER MORTGAGE INTERESTsince 02/26/2010
UNITED STATES DEPARTMENT OF AGRICULTURE - RURAL DEVELOPMENTOrganization5% OR GREATER MORTGAGE INTERESTsince 12/01/2016
HOLZEM, TARAIndividualW-2 MANAGING EMPLOYEEsince 05/24/2014
CLAPP, ROGERIndividualCORPORATE DIRECTORsince 07/01/2011
FRITZ, PERRYIndividualCORPORATE DIRECTORsince 07/01/2014
GENSCH, BRIANIndividualCORPORATE DIRECTORsince 05/01/2017
HAMER, STEPHENIndividualCORPORATE DIRECTORsince 07/01/2011
HOUWERS, JAMESIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/01/2011
ISKEN, KEITHIndividualCORPORATE DIRECTORsince 05/01/2017
KERPE, MARSHAIndividualCORPORATE DIRECTORsince 07/01/2011
PRICE, JAMESIndividualCORPORATE DIRECTORsince 07/01/2011
THEUNE, DORISIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/01/2011
THOMPSON, CYNTHIAIndividualCORPORATE DIRECTORsince 07/01/2015
TRAGER, MARGARETIndividualCORPORATE DIRECTORsince 05/01/2017
VANDEWATER, DAVIDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/01/2014
TREFFERT, PAULIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2016

CMS files one row per role, so the 19 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.2M
Net patient revenuemost recent cost report
-18.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 41%Medicare 4%Other / private 55%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$472per resident / day
operating cost
$14,340per month
≈ monthly operating cost
$397per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.

Typical monthly cost in Wisconsin
$10,646/mo
Nursing home (semi-private)
$12,319/mo
Nursing home (private)
$6,540/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525598. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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