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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
No Medicare penalties on record
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 38% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
RN hours are below the EveryPlace reference benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
8
measures
8
measures
1
measures
Residents whose walking got worse
Residents needing more daily help over time
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for the flu
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility has significant compliance concerns with families filing formal complaints about care quality and abuse reporting. The most recurring issues involve fire safety and building code violations, medication management (particularly unnecessary drugs), and resident rights protections. While most deficiencies show correction plans, persistent problems with infection control, emergency power systems, and pharmacy services appear across multiple surveys, suggesting ongoing operational challenges that families should carefully evaluate during visits.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Construction Deficiencies
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Smoke Deficiencies
Provide properly protected cooking facilities.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Nutrition and Dietary Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Pharmacy Service Deficiencies
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.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Administration Deficiencies
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.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Pharmacy Service Deficiencies
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.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Sheboygan Senior Community INC
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Key personnel
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