Sheboygan Progressive Health Services

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 residents (R) (R1 and R2) of 7 sampled residents received care and treatment based upon comprehensive assessments and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change in condition. The day after an unwitnessed fall, R1 presented with a change of condition including increased pain, decreased appetite, reduced fluid intake, and decreased mobility. The facility did not ensure a nursing assessment was completed or notify R1's physician and Power of Attorney for Healthcare (POAHC) in a timely manner. R1's pain and decreased intake continued until they were transferred to the hospital 4 days after the fall. R1 was diagnosed with minimally displaced left lateral L2 and L3 transverse process fractures and a mild compression fracture of the T12 vertebral body. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure assistive devices to prevent accidents were implemented for 1 resident (R) (R1) of 3 residents from a total sample of 9 residents. R1 had an unwitnessed fall while self-transferring from wheelchair to toilet. Staff did not ensure R1's chair alarm was in place prior to the fall. R1 was transferred to the hospital and diagnosed with minimally displaced left lateral L2 and L3 (lumbar spine/lower back) transverse process fractures and a mild compression fracture of the T12 vertebral body (junction between the mid and lower back).

Inspectors wroteBased on interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Registered Nurse (RN)-E) of 9 employees reviewed for caregiver background checks. The facility did not complete a thorough background check for RN-E.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being related to wound management for 1 resident (R) (R6) of 2 sampled residents. The facility did not monitor and assess R6's left lower extremity venous stasis wound in accordance with R6's physician order and plan of care. In addition, the facility's wound nurse was not aware that the wound had re-opened.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure care and treatment was provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R7) of 3 sampled residents. R7 had multiple healed wounds, including a stage 1 pressure injury on the coccyx, and had an unhealed abrasion on the left scapula. During observations on 8/12/25 and 8/13/25, R7's air mattress was not set to the appropriate setting. Findings Include: The facility's Pressure Injuries and Non-Pressure Injuries policy, dated 7/20/22, indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R22) of 2 sampled residents. R22 had an order for continuous positive airway pressure (CPAP) for obstructive sleep apnea. The facility did not clean R22's CPAP machine per manufacturer's instructions.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure pureed food was prepared in a method that conserved the nutritive value for 3 residents (R) (R22, R35, and R40) of 3 sampled residents who had orders for pureed diets. Staff did not follow recipes while pureeing food to ensure the nutritive value was conserved. In addition, staff did not offer residents on a pureed diet one of the items as listed on the menu and the residents' meal tickets.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R27 and R28) of 8 sampled residentsR27 had an open chronic wound. Enhanced barrier precautions (EBP) were not implemented for R27. R28 had an indwelling urinary catheter. EBP was not initially implemented for R28. After EBP was implemented on 8/12/25, Surveyor observed staff provide care without donning the appropriate personal protective equipment (PPE).

Inspectors wroteBased on staff interview and record review, the facility did not implement their written policy and procedure to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property for 1 (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for caregiver background checks. CNA-C's background check information indicated CNA-C was convicted of disorderly conduct in 2022 and 2025. The facility did not request a copy of CNA-C's criminal complaint, judgement of conviction, or relevant court and police documents as instructed by the Background Information Disclosure (BID) form and Department of Health Services (DHS) memo P-00274 Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R4) of 18 sampled residents. On 2/27/25, R4 was observed self-administering medication. During the observation, R4 dropped pills in R4's bed and was unable to find them. R4 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R4 could self-administer medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 31 residents residing in the facility. Procedures for reheating food in a microwave were not followed. Cooling temperature logs were not completed for leftover and pre-made food. Cold food items were not maintained at a proper temperature during meal service. Staff did not complete appropriate hand hygiene during meal service.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the required Minimum Data Set (MDS) assessment data was transmitted timely for 3 residents (R) (R45, R46 and R47) of 4 residents reviewed for MDS completion. Two of R45's MDS assessments, both dated 1/30/24, did not have completed transmissions as of 6/17/24. Two of R46's MDS assessments, dated 11/29/23 and 12/15/23, did not have completed transmissions as of 6/17/24. Two of R47's MDS assessments, both dated 7/2/23, did not have completed transmissions as of 6/17/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R24 and R10) of 5 sampled residents. R24 experienced a fall due to an improper sling size for a sit-to-stand (STS) lift when only one staff was present during the transfer. R10 experienced pain due to an improper sling size for a STS lift when only one staff was present during the transfer.

Inspectors wroteBased on staff and resident interview and record review, the facility did not make a prompt effort to thoroughly investigate and resolve grievances for 1 Resident (R) (R1) of 5 sampled residents. On 2/15/24, R1 expressed grievances during a meeting with staff and Ombudsman (OMB)-C. The grievances were not investigated or resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R48) of 3 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent accidents. R48 was at risk for falls. R48's care plan contained interventions for the assistance of one staff and a gait belt for transfers. R48 had a functional maintenance program (FMP) from therapy that was not given to nursing or incorporated in R48's plan of care. The FMP indicated R48 was to be transferred with a front wheeled walker in addition to a gait belt. R48 was transferred without a front wheeled walker and/or gait belt twice. R48 fell twice on R48's right leg below-the-knee post amputation surgical site and required two additional surgeries to close the site.

Inspectors wroteBased on observation and resident and staff interview, the facility did not ensure call lights were within reach for 2 Residents (R3 and R25) of 17 residents reviewed. R3 was observed on multiple occasions in R3's room without a call light within reach. R25 was observed without a call light within reach in R25's room.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure care plan interventions were followed for 2 Residents (R) (R33 and R2) of 17 residents reviewed. R33 had care plan interventions for a splint on the left hand and a pillow under R33's right arm. The interventions were not consistently implemented. R2 had care plan interventions for padded side rails and bed in a low position. The interventions were not consistently implemented.

Inspectors wroteBased on observation and staff interview, the facility did not ensure medications were dispensed and administered in accordance with the facility's self-administration policy for 1 Resident (R) (R22) of 17 residents. Surveyor observed a medication cup that contained 2 white oblong pills on R22's bedside table. R22 did not have an assessment for self-administration of medication or a physician's order to self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a timely physician response to pharmacy recommendations for 2 Residents (R) (R33 and R40) of 5 residents reviewed for unnecessary medications. R40 had pharmacy recommendations for gradual dose reductions on 11/23/22 and 12/20/22. The recommendations were not addressed timely. R33 had a pharmacy recommendation for a gradual dose reduction on 12/20/22. The recommendation was not addressed timely.

Inspectors wroteBased on staff interview and record review, the facility did not ensure required nurse aid training was completed for 1 of 2 Certified Nursing Assistants (CNAs) reviewed. CNA-E worked in the facility as an agency CNA. The facility was unable to provide evidence CNA-E received the required training which included abuse and neglect, dementia care, and care for individuals with cognitive disabilities.

Inspectors wroteBased on staff interview, the facility did not ensure 15 of 15 Certified Nursing Assistants (CNAs) received annual performance reviews. The facility was unable to provide evidence CNAs received annual performance reviews.