Sheboygan Senior Community Inc

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.