Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Senior Community Inc during CMS and state inspections, most recent first.
A resident with diabetes, peripheral artery disease, a prior BKA, and a chronic left heel ulcer received an Apligraf skin graft from podiatry with explicit orders not to disturb the graft or inner dressings until the next follow‑up. An LPN documented the "DO NOT REMOVE" instruction, but the order was not promptly entered into the TAR, and subsequent wound care orders in the record were overlapping and ambiguous. The resident later reported that a nurse removed pieces of the graft the day after application and re‑dressed the wound, and staff interviews confirmed confusion about the wound care orders and lack of a formal double‑check process for order entry. At the next wound clinic visit, the graft was found to be missing and the ulcer had worsened, and clinic and podiatry staff reported receiving no calls from the facility to clarify or report removal of the graft, demonstrating failure to provide care in accordance with physician orders.
The facility did not report two incidents of resident abuse to the State Agency as required. One resident with severe cognitive impairment was involved in aggressive actions towards two other residents, including an attempted stabbing and a wheelchair altercation. Despite internal reporting, the Nursing Home Administrator decided not to report these incidents externally, violating the facility's policy and regulatory standards.
The facility failed to thoroughly investigate abuse allegations involving a resident with severe cognitive impairment who was aggressive towards two other residents. The investigations were incomplete, with missing documentation and confusion over dates and times. The facility did not document the necessary details to form a reasonable conclusion about the incidents, leading to a deficiency identified by the surveyor.
The facility did not ensure that the Dietary Manager met the minimum qualifications, affecting all 55 residents. The DM had not completed a certification course and their ServSafe certification had expired. The NHA confirmed the DM was not certified or enrolled in a training program, citing budget constraints.
The facility failed to maintain sanitary food storage and preparation practices, affecting nearly all residents. Observations included incomplete cooling and temperature logs, improper hand hygiene, and lack of hair restraints in the kitchen. Staff did not consistently monitor food temperatures or follow reheating procedures, and sanitization logs were incomplete. These deficiencies indicate a failure to adhere to food safety protocols, posing a risk of foodborne illness.
The facility failed to ensure the QAA committee met the required membership and frequency. The QAPI Plan was undated and lacked specific policies. The committee did not meet in certain quarters, and some meetings lacked required members like the Medical Director and Infection Preventionist. The NHA confirmed the accuracy of the meeting records.
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete infection line lists and inadequate tracking of infections. The Director of Nursing, who was also the Infection Preventionist, confirmed these deficiencies and had only recently started infection control training.
The facility did not ensure that the designated Infection Preventionists (IPs), including the DON and an RN, completed specialized training in infection prevention and control. This oversight had the potential to affect all 55 residents. The DON had only completed two modules of the required training, and the NHA confirmed the lack of a qualified IP after the previous IP left the facility.
The facility failed to maintain resident dignity during meal times, as vital signs were taken at the dining table and medications were administered during meals. Residents experienced significant delays in meal service, with some finishing their meals while others were still waiting to be served. Staff and residents confirmed these issues, highlighting a lack of coordination in the dining service process.
The facility failed to monitor four residents for adverse reactions or side effects of psychotropic medications, despite care plans indicating the need for such monitoring. Interviews revealed that staff observed behavior but did not routinely document potential adverse drug reactions, and there was no accessible reference for medication side effects. This issue was consistent across the sampled residents, highlighting a systemic problem in medication management.
A resident with severe cognitive impairment and an activated POA was not involved in care planning at the LTC facility. Despite the need for regular care conferences, only one was held since admission, and the POA was not informed or involved in ongoing care decisions. The facility lacked a process for tracking care conferences and did not provide a care conference policy.
A resident was not provided with a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form when their Medicare Part A coverage ended, leading to a deficiency. The facility failed to inform the resident of their financial liability and appeal rights, as the social worker did not provide the ABN form due to the facility's infrequent handling of Medicare residents.
The facility failed to provide written transfer notices to three residents with severely impaired cognition when they were transferred to the hospital. The notices, which should have included transfer details and appeal rights, were not given to the residents or their POAs. Interviews revealed confusion among staff about responsibility for issuing these notices, contributing to the deficiency.
The facility failed to provide written bed-hold notices to three residents and their representatives during hospital transfers, as required by policy. Despite severe cognitive impairments and activated POAs, the residents did not receive the necessary documentation. Interviews confirmed the oversight, and the DON acknowledged the need for staff education on this requirement.
A resident with a history of heart failure, CKD, and dementia experienced a CVA and was later diagnosed with Parkinson's disease. The facility did not update the resident's care plan to reflect these new diagnoses. This deficiency was confirmed by the DON during a surveyor interview.
A resident with severe cognitive impairment and multiple health conditions experienced a significant weight loss of 12.14% over six months. The facility failed to consistently obtain and document the resident's weekly weights as ordered, and there was no evidence that the resident's Power of Attorney for Healthcare, physician, or dietitian were notified of the weight loss. The Director of Nursing acknowledged that the weight loss was missed by the team, and no re-weighing or investigation was conducted, contributing to the deficiency.
A resident prescribed clopidogrel, a high-risk anticoagulant, was not monitored for adverse reactions or side effects due to the absence of monitoring interventions in their care plan. Facility staff, including an LPN and the DON, confirmed the lack of consistent side effect monitoring for high-risk medications, with the LPN relying on external sources for information.
A facility failed to have a written contract or agreement for dialysis services for a resident with stage 5 renal disease receiving hemodialysis thrice weekly. The facility also lacked a policy or procedure for dialysis treatment. Both the Health Services Specialist and the Nursing Home Administrator confirmed the absence of necessary documentation, with the administrator unaware of the requirement due to the facility's infrequent handling of dialysis patients.
Failure to Follow Wound Care Orders for Diabetic Heel Ulcer Skin Graft
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care was provided in accordance with a physician’s orders for a resident with a diabetic heel ulcer being treated with Apligraf skin grafts. The resident had multiple comorbidities including diabetes with polyneuropathy, peripheral artery disease, a prior right below‑knee amputation, and a chronic left posterior ankle/heel diabetic ulcer with visible tendon. Podiatry applied an Apligraf graft to the left heel on 11/3/25 with clear instructions that the graft and underlying dressings (Adaptic and Steri‑Strips) were not to be disturbed until the resident’s follow‑up the next week. A progress note by an LPN on 11/3/25 documented “Wound graft #2 placed on left foot. DO NOT REMOVE.” However, this order was not entered into the Treatment Administration Record (TAR) on the day of the visit. Subsequent wound care orders in the TAR showed overlapping and changing instructions, including orders to cleanse the wound and apply Hydrofera blue and orders specifying not to remove the skin graft or inner dressings. There were also TAR entries stating “DO NOT REMOVE DRESSING AT LEFT ANKLE UNTIL SEEN AT WOUND CLINIC. NEW GRAFT PLACED” with every‑shift frequency. Staff interviews revealed confusion about the wound care orders, with staff recalling standing instructions to change only the outer dressing and not to disturb inner dressings unless saturated, but also acknowledging that there was no consistent oversight of wound care orders and no formal double‑check process for order entry. The DON confirmed that the facility’s order entry policy did not address verification or double‑checking of newly entered orders and described the process in which LPNs entered orders from paper or faxed documents without a structured second review. The resident, who was cognitively intact and made their own healthcare decisions, reported that the day after the second Apligraf was applied, a nurse reacted to the appearance of the heel, left the room, returned with supplies, wetted the wound, and pulled pieces of the graft off. The resident stated that the same nurse later returned with another nurse and re‑did the dressing. The resident did not report this to facility staff at the time but informed the wound clinic at the next scheduled visit. At the 11/11/25 wound clinic appointment, wound care staff documented that when the dressing was removed, the Apligraf was missing and the wound contained a significant amount of boggy, non‑viable hypergranulation tissue, and the resident required surgical debridement and IV antibiotics. Wound clinic staff and podiatry office staff confirmed there were no calls from the facility to clarify orders or report removal of the graft. Facility staff interviews indicated that one nurse told the scheduler that another nurse had removed the Apligraf because the nurse did not see the new order, and that this information was not escalated to leadership. The DON stated they were not aware that the graft had been removed and acknowledged that the wound care orders were ambiguous. Additional documentation from wound care, infectious disease, vascular surgery, and podiatry after the hospitalization described the subsequent management of the resident’s heel wound, including diagnoses of calcaneal osteomyelitis and partial calcanectomy, and the use of IV and oral antibiotics. These records confirmed that the graft was no longer present at the time of the 11/11/25 visit and that the wound had worsened. The wound clinic nurse explained that the Apligraf requires at least 48 hours to adhere and that the 11/3/25 order specified no dressing changes, verifying that the graft should not have been removed. The combination of delayed and incomplete order entry, lack of a verification process for new orders, staff confusion about wound care instructions, and failure to clarify or communicate with the podiatry or wound clinic providers led to the Apligraf being removed contrary to orders and not being reported, constituting the cited deficiency in providing care according to physician orders.
Failure to Report Resident Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the State Agency as required by their policy and regulatory standards. On November 22, 2024, a resident reported that another resident had been physically aggressive towards them the previous day, including an attempt to stab with a utensil. Additionally, on the same day, the aggressive resident initiated an altercation with another resident by shaking their wheelchair. Despite these incidents being reported internally to the Nursing Home Administrator, the decision was made not to report them to the State Agency. The involved residents had varying levels of cognitive impairment, with one having severe cognitive impairment and the others having moderate to no cognitive impairment. The facility's policy mandates immediate reporting of such incidents to the State Agency, but this was not adhered to. The Director of Nursing and Social Worker acknowledged that the incidents should have been reported from a regulatory standpoint, but the Nursing Home Administrator chose not to report them. The facility's failure to report these incidents represents a deficiency in adhering to abuse reporting requirements.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations involving two residents. On November 22, 2024, a resident reported that another resident had been physically aggressive towards two other residents on separate occasions. The facility's policy requires immediate and thorough investigations of such incidents, but the investigations were not adequately conducted. The Director of Nursing and Social Worker acknowledged that the investigations were incomplete, with missing documentation and confusion over dates and times. The facility did not document the necessary details to form a reasonable conclusion about the incidents. The incidents involved a resident with severe cognitive impairment who was aggressive towards two other residents, one with moderate cognitive impairment and another without cognitive impairment. The aggressive resident had a history of Alzheimer's disease and was on 1:1 supervision following the incidents. However, the documentation of the supervision was not filed in the medical record, and the grievance investigation was backdated. The facility's failure to conduct thorough investigations and maintain proper documentation led to the deficiency identified by the surveyor.
Unqualified Dietary Manager in LTC Facility
Penalty
Summary
The facility failed to ensure that the individual designated as the food and nutritional services director met the minimum qualifications for the role, which had the potential to affect all 55 residents residing in the facility. The Dietary Manager (DM) had not completed an approved dietary manager or food service manager certification course or other related education. During an interview, the DM indicated that they had been working in the facility for several years and had been the Dietary Manager for 3 to 4 years. Although the DM was ServSafe certified, their certification expired in August, and they had not renewed it. Furthermore, the DM was not currently enrolled in a dietary or food service manager certification course. The Nursing Home Administrator (NHA) confirmed that the DM was not certified or enrolled in a certified training program. The NHA stated that it was not in the facility's budget to get the DM certified.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, potentially affecting 54 of 55 residents. The surveyor observed that cooling temperature logs were not completed for leftover and pre-made food, and staff did not consistently monitor or document cooked food temperatures or hot/cold holding temperatures. Additionally, staff failed to test or document the parts per million (PPM) of the quaternary sanitizing solution as per the manufacturer's instructions, and did not monitor and document dishwasher and surface temperatures. Furthermore, staff did not follow procedures for reheating food in a microwave, and did not wear hair restraints when entering the kitchen where resident food was prepared. During the survey, it was noted that staff did not perform appropriate hand hygiene and safe food handling practices when serving food. For instance, a dietary aide was observed donning gloves without completing hand hygiene, touching various food items with gloved hands, and changing gloves multiple times without washing hands in between. This lack of proper hand hygiene was confirmed by the dietary aide during an interview. Additionally, the surveyor observed that staff did not check the temperature of the food prior to serving, and a hot holding cart containing food was not plugged in, leading to food being served at improper temperatures. The surveyor also noted that the facility's sanitization logs for the three-compartment sink and dishwasher were incomplete, with missing entries for several months. The dietary manager acknowledged these inconsistencies and stated that logs should be completed each time the sink is filled and that test strips should be run through the dishwasher once per day. Furthermore, staff were observed entering the kitchen without wearing hair restraints, which is against the facility's policy and the FDA Food Code. These observations indicate a failure to adhere to established food safety and hygiene protocols, posing a risk of foodborne illness to residents.
QAA Committee Membership and Meeting Frequency Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met the required membership and frequency of meetings. The facility did not have documentation indicating that the QAA committee, which should include the Director of Nursing (DON), Medical Director or designee, Infection Preventionist, and at least three other staff members including the Nursing Home Administrator (NHA), met at least quarterly. The QAPI Plan provided was undated, appeared to be a template, and did not specify the facility's specific policy, procedure, or the required members and frequency of meetings. Upon review of the QAA committee meeting sign-in sheets, it was noted that the committee did not meet during the third quarter of 2023 and the second quarter of 2024. Additionally, the fourth quarter meeting of 2023 did not include the Medical Director or designee, the first quarter meeting of 2024 lacked sufficient staff members, and the third quarter meeting of 2024 did not include the Infection Preventionist. The NHA confirmed that the sign-in sheets accurately reflected the committee's meeting dates and attendance, indicating a failure to comply with the required structure and frequency of QAA meetings.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which is crucial for providing a safe and sanitary environment and preventing the transmission of communicable diseases and infections. The facility's policy on Surveillance for Infections, dated September 2017, outlines the responsibilities of the Infection Preventionist (IP) in conducting ongoing surveillance for healthcare-associated infections (HAIs) and other significant infections. However, the facility did not appropriately monitor residents and staff for infections and outbreaks, as evidenced by incomplete infection line lists and inadequate tracking and trending of infections. During the survey conducted from September 23 to September 25, 2024, the surveyor reviewed the facility's infection line lists for residents and staff. The line lists provided were incomplete, lacking essential details such as symptoms, laboratory results, and the dosage or duration of antibiotics used. Additionally, the line lists did not track and trend infections or contain monthly infection rates or percentages. The Director of Nursing (DON), who was also assigned the IP role, confirmed these deficiencies and indicated that they had only recently started infection control training, having completed only two modules so far.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that a designated Infection Preventionist (IP) completed specialized training in infection prevention and control, which had the potential to affect all 55 residents. The Director of Nursing (DON)-B and Registered Nurse (RN)-E were assigned as the facility's IPs but had not completed the necessary training. The facility's policy requires the IP to be qualified by education, training, experience, and/or certification, and to provide evidence of training through certificates or equivalent documentation. During an interview, DON-B stated that they started at the facility on July 8, 2024, and were assigned the IP role. However, DON-B had only completed two modules of the IP training. The Nursing Home Administrator (NHA)-A confirmed that the facility did not have a qualified IP, as the previous DON and IP had left the facility on June 30, 2024. NHA-A mentioned plans to have a consultant monitor DON-B and another nurse to maintain the infection prevention and control program.
Dignity and Meal Service Deficiency
Penalty
Summary
The facility failed to maintain the dignity of residents during meal times, as observed by surveyors. In the Oak dining room, a resident's vital signs were taken at the dining table while other residents were present, and medications were administered to residents during their meals. Additionally, residents at the same table were not served their meals simultaneously, leading to some residents finishing their meals while others were still waiting to be served. This was observed on multiple occasions, with significant delays in meal service, causing discomfort and dissatisfaction among the residents. Interviews with staff and residents confirmed these observations. A Dietary Aide admitted to cooking and serving meals one by one, which often took an hour, while a Licensed Practical Nurse acknowledged that vital signs should not be taken at the dining table unless a resident is in distress. Residents expressed feelings of awkwardness and dissatisfaction with the meal service, noting that it felt more like a hospital environment. Staff members also reported that residents became anxious and complained about the delays in receiving their meals, indicating a lack of coordination and efficiency in the dining service process.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that four residents who were prescribed psychotropic medications were adequately monitored for adverse reactions or side effects. These residents included individuals with severe cognitive impairments and various diagnoses such as Alzheimer's disease, depression, and anxiety. Despite having care plans that required monitoring for the effectiveness and adverse effects of these medications, the facility did not implement specific monitoring interventions or conduct baseline and ongoing assessments for these residents. For instance, one resident was prescribed lorazepam, sertraline, and quetiapine, yet their medical record lacked documentation of monitoring for adverse reactions or side effects. Interviews with the Director of Nursing and a Licensed Practical Nurse revealed that while staff observed residents' behavior and monitored for sleepiness, there was no routine documentation of potential adverse drug reactions. Additionally, there was no accessible reference for nursing staff to identify potential medication side effects, leading them to rely on external sources like the internet or reference books. Another resident, who had intact cognition, was prescribed Seroquel for visual hallucinations, but their medical record did not include any monitoring interventions for adverse reactions or side effects. The Director of Nursing confirmed the absence of such monitoring in the resident's medical record, acknowledging that it should have contained interventions for staff to be aware of potential adverse reactions. This lack of documentation and monitoring was consistent across the sampled residents, indicating a systemic issue within the facility's medication management practices.
Failure to Involve POA in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their activated Power of Attorney (POA) were involved in the development and implementation of the resident's person-centered plan of care. The resident, who was admitted with diagnoses including cerebral infarction, epilepsy, and cognitive communication deficit, had severely impaired cognition and an activated POA. Despite these conditions, the facility only conducted one care conference since the resident's admission, which occurred on 9/17/21. The facility did not offer or document any additional care conferences, nor did they involve the POA in ongoing care planning. Interviews with the POA and the Social Worker (SW) revealed that the POA was not involved in the resident's care planning and had not attended any care conferences since the resident's admission. The POA expressed a desire to participate in care conferences and decision-making but was not aware of any being scheduled. The SW confirmed the lack of care conferences and acknowledged that the facility did not have a process for tracking them, relying instead on annual scheduling. The facility failed to provide a care conference policy, and there was no documentation indicating that care conferences were offered or declined.
Failure to Provide ABN Form to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R109, received and signed a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form. This form is crucial for informing residents about the end of their Medicare Part A coverage, their potential financial liability for continued services, and their rights to appeal claims. The deficiency was identified during a survey conducted from September 23 to September 25, 2024, where it was found that R109 was not provided with the ABN form when their Medicare benefits ended on May 16, 2024, despite remaining in the facility. The surveyor's review of R109's medical records revealed that the resident was given a Notice of Medicare Non-Coverage (NOMNC) form, indicating the end of services on May 16, 2024. However, the facility only provided a generated form that stated the last day of Medicare coverage and the start of private pay without including necessary information such as standard claim appeals rights. An interview with the social worker, SW-C, revealed that the facility rarely had Medicare residents, leading to the omission of providing the Medicare ABN form to residents who continued to stay in the facility.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to three residents, R1, R19, and R32, when they were transferred to the hospital. These notices should have included the date of transfer, reason for transfer, location of transfer, and appeal rights. R1 was transferred due to abdominal pain, R19 due to a fall, and R32 due to a change in condition. All three residents had severely impaired cognition and activated Powers of Attorney (POA), yet neither the residents nor their POAs received the required written notices. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing transfer notices. The Social Worker indicated that nursing staff were responsible for providing these notices, while the Director of Nursing was unaware that a written notice should be given each time a resident is transferred. This confusion led to the failure to provide the necessary documentation to the residents and their representatives, as confirmed by the Director of Nursing during the survey.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed-hold notices to three residents (R1, R19, and R32) and their representatives upon their transfer to a hospital, as required by the facility's policy. The policy mandates that residents and their representatives receive written information about the bed-hold policy, reserve bed payment policy, and the right to return to the facility at the time of transfer. However, the medical records for R1, R19, and R32 did not indicate that such notices were provided. Interviews with the residents' representatives and facility staff confirmed the absence of these notices. R1, who had severe cognitive impairment and an activated Power of Attorney (POA), was transferred to the hospital for abdominal pain, while R19, also with severe cognitive impairment and an activated POA, was transferred due to a fall. R32, with similar cognitive challenges, was transferred due to a change in condition. Despite the facility's policy, the Director of Nursing (DON) and other staff members were unaware that a written notice should accompany each transfer, leading to a failure in communication and documentation. The DON confirmed that the nursing staff needed education on this requirement.
Failure to Update Care Plan for New Diagnoses
Penalty
Summary
The facility failed to ensure that the care plan for a resident, identified as R32, was reviewed and revised to address new medical diagnoses. R32, who had a history of heart failure, chronic kidney disease, and dementia, was admitted to the hospital for a cerebrovascular accident (CVA) and later diagnosed with Parkinson's disease. Despite these significant changes in R32's medical condition, the care plan was not updated to reflect the new diagnoses. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan should have been updated following the new diagnoses.
Failure to Monitor and Address Resident's Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R19, received the necessary care and services to prevent or monitor weight loss. R19, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, dementia, congestive heart failure, chronic kidney disease, and peripheral vascular disease, was supposed to have weekly weights recorded as per physician's orders. However, the facility did not consistently obtain and document these weights. The resident experienced a severe weight loss of 12.14% over six months, with significant weight loss noted between 8/28/24 and 9/11/24. Despite the facility's policy requiring significant weight changes to be reported and addressed, there was no documentation indicating that R19's Power of Attorney for Healthcare, physician, or dietitian were notified of the weight loss. The Director of Nursing (DON) acknowledged that weights should be completed as ordered and that the facility's system used red flags to indicate significant weight differences. However, the DON admitted that the red-flagged weight loss for R19 on 9/11/24 was missed by the team, and no re-weighing or investigation was conducted. Additionally, weights were missing on several dates, including 9/18/24, which was supposed to be a scheduled weigh day. The lack of follow-up and documentation regarding the resident's weight loss and the failure to adhere to the facility's policy contributed to the deficiency identified by the surveyor.
Failure to Monitor High-Risk Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse reactions or side effects of a high-risk medication. The resident, identified as R208, was prescribed clopidogrel, an anticoagulant medication, but their care plan did not include monitoring interventions for potential adverse reactions or side effects. The resident's medical record, including the Medication Administration Record (MAR), lacked any orders for monitoring these side effects, despite the known risks associated with clopidogrel. Interviews with facility staff revealed a lack of awareness and documentation regarding the monitoring of medication side effects. A Licensed Practical Nurse (LPN) stated that there was no designated place in the resident's medical record for documenting or monitoring medication side effects and that they relied on external sources to understand potential side effects. The Director of Nursing (DON) confirmed that side effect monitoring was not consistently implemented for residents receiving high-risk medications, acknowledging that such interventions should be documented in the resident's medical record.
Lack of Contract and Policy for Dialysis Services
Penalty
Summary
The facility failed to acquire a current contract or agreement in writing for outside dialysis services for a resident who required dialysis treatment. The resident, identified as R360, was admitted with diagnoses including hypertensive chronic heart and kidney disease with stage 5 renal disease and received hemodialysis three times weekly. Upon review, the surveyor found that the facility did not have a contract with the dialysis provider, nor did it have a policy or procedure related to dialysis treatment. Both the Health Services Specialist and the Nursing Home Administrator confirmed the absence of a contract and policy, with the administrator unaware that such documentation was required, as the facility did not typically have dialysis patients.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Sheboygan Health Services | 2.3 mi | — | 7 | 0 |
| Edenbrook Sheboygan | 2.6 mi | — | 6 | 1 |
| Morningside Health Services | 2.9 mi | — | 7 | 0 |
| Sheboygan Progressive Health Services | 4.5 mi | — | 0 | 0 |
| Meadow View Health Services | 5.3 mi | — | 8 | 0 |
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