Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheboygan Progressive Health Services during CMS and state inspections, most recent first.
The facility did not follow its policy to prevent abuse and neglect by failing to obtain necessary documents for a CNA with disorderly conduct convictions. Despite the requirement for full background checks, the facility did not request additional information for the CNA's convictions, leading to a noted deficiency.
A resident was observed self-administering medication without a physician's order or assessment, leading to dropped pills in bed. Despite having no cognitive impairment, the resident had a recent change in condition requiring IV fluids and oxygen. The facility's policy requires an order and assessment for self-administration, which were missing in this case.
The facility failed to ensure food safety and sanitation, affecting all 31 residents. Observations revealed improper reheating of food, incomplete cooling logs, and inadequate temperature maintenance for cold foods. Additionally, staff did not follow proper hand hygiene and glove use during meal service, leading to potential contamination.
The facility failed to transmit MDS assessments timely for three residents, resulting in a deficiency. Completed assessments were not accepted by the iQIES system due to a coding error in the EMR system. The Director of Clinical Reimbursement confirmed the oversight, noting that the assessments were marked as completed but not transmitted. The MDS nurse was still in training, and regional staff were responsible for the transmission process.
Two residents experienced issues during transfers due to improper sling sizes and inadequate staffing. One resident fell when a sling was too large, and only one staff member was present, while another resident experienced pain from a sling that was too small. Staff interviews revealed confusion about sling sizing and transfer procedures, with no clear responsibility for documenting sling sizes in care plans.
Failure to Implement Background Check Policy for CNA
Penalty
Summary
The facility failed to implement its written policy and procedure to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property. This deficiency was identified during a review of the background check process for a Certified Nursing Assistant (CNA-C) who was one of eight staff members reviewed. CNA-C had been convicted of disorderly conduct in 2022 and 2025, but the facility did not request the necessary criminal complaint, judgment of conviction, or relevant court and police documents as required by the Background Information Disclosure (BID) form and the Department of Health Services (DHS) memo P-00274 Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility. The facility's Caregiver Background Checks policy, revised in August 2017, mandates that any reported history of criminal activity be reviewed by the Human Resources Department for further consideration in hiring decisions. However, the Nursing Home Administrator (NHA-A) confirmed that the facility did not obtain the additional information related to CNA-C's disorderly conduct convictions. This oversight occurred despite the requirement for all staff to undergo a full background check prior to employment. The failure to adhere to these procedures resulted in a deficiency noted by the surveyor during the review conducted on February 27, 2025.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medication for one resident. The resident, identified as R4, was observed self-administering medication without a physician's order or a self-administration assessment. During the observation, R4 dropped pills in the bed and was unable to find them. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine if self-administration is safe for the resident. However, R4's medical record did not contain the necessary documentation to support self-administration of medication. R4 was admitted with diagnoses including diabetes, weakness, chronic pain, and hypertension, and had a BIMS score indicating no cognitive impairment. Despite this, R4 experienced a change in condition and was prescribed intravenous fluids and oxygen. The Director of Nursing and a Registered Nurse confirmed that R4 did not have the required order or assessment for self-administration. The RN admitted to leaving medication for R4 to self-administer, acknowledging that this was inappropriate given R4's recent change in condition.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a safe and sanitary manner, potentially affecting all 31 residents. During a kitchen tour, it was observed that procedures for reheating food in a microwave were not followed. A staff member heated tomato soup in the microwave without checking its temperature or ensuring it reached the required 165 degrees Fahrenheit. The staff member was unaware of the proper reheating procedures, including the need to stir, cover, and let the food stand for two minutes after reheating. Additionally, the facility did not maintain proper cooling temperature logs for leftover and pre-made food. A container of leftover ravioli was found without documentation on the cooling log, and a new cook was unaware of the documentation procedures. Similarly, a container of macaroni salad prepared the previous day was not documented on the cooling log, despite being cooled using appropriate methods. The facility's Regional Dietary Manager confirmed the need for documentation and acknowledged the oversight. The facility also failed to maintain cold food items at the proper temperature during meal service. Macaroni salad was initially found at temperatures above the safe limit and was not maintained at the correct temperature throughout the lunch service. Furthermore, staff did not complete appropriate hand hygiene during meal service. A staff member was observed donning gloves without washing hands and handling food and utensils improperly, leading to potential contamination. Despite intervention and education from the Regional Dietary Manager, the staff member continued to make errors in hand hygiene and glove use.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessments for three residents, resulting in a deficiency. The assessments for these residents were completed but not accepted by the iQIES system, indicating a failure in the transmission process. Specifically, two assessments for one resident dated January 30, 2024, two assessments for another resident dated November 29, 2023, and December 15, 2023, and two assessments for a third resident dated July 2, 2023, were not transmitted as required. This failure was identified during a survey conducted on June 17, 2024. The deficiency was attributed to a coding error within the facility's electronic medical record (EMR) system, as confirmed by the Director of Clinical Reimbursement (DCR). The DCR acknowledged that the assessments were marked as completed but were not transmitted or accepted by the iQIES system. The MDS nurse, who was still in training, and the regional staff were responsible for the transmission process. However, the DCR admitted to not checking the iQIES system for missing assessment reports, which contributed to the oversight.
Improper Sling Use and Staffing During Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R24 and R10, due to improper use of slings during transfers with a sit-to-stand (STS) lift. R24 experienced a fall when a sling that was too large was used, and only one staff member was present during the transfer, contrary to the facility's policy requiring two staff members. The CNA involved was aware of the policy but proceeded without assistance due to unavailability of a second staff member. The CNA also admitted to not knowing how to determine the correct sling size, which contributed to the incident. R10 experienced pain during transfers due to the use of a sling that was too small. The care plan for R10 specified the use of a standard size sling with two staff members, but the resident reported that the smaller sling was used multiple times per week, causing discomfort. The CNA responsible for R10's transfer confirmed that the standard size sling caused pinching and pain, indicating a need for a larger sling. However, the appropriate size sling was not readily available, and the staff were unsure of how to determine the correct size. Interviews with various staff members, including CNAs, LPNs, and RNs, revealed inconsistencies in understanding and implementing the facility's policies on sling sizing and transfer procedures. The Director of Nursing and Nursing Home Administrator were unaware of the specific incidents involving R10's pain and the improper sling size. There was no clear responsibility assigned for documenting sling sizes in residents' care plans, leading to confusion and improper handling of residents during transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sheboygan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow View Health Services | 0.8 mi | — | 8 | 0 |
| Edenbrook Sheboygan | 1.9 mi | — | 6 | 1 |
| Sheboygan Health Services | 2.3 mi | — | 7 | 0 |
| Morningside Health Services | 3.7 mi | — | 7 | 0 |
| Sheboygan Senior Community Inc | 4.5 mi | — | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.