Sheboygan Health Services

In the surveyor’s words

From the most serious findings on record at Sheboygan Health Services, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 19, 2026

  Based 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 42 residents residing in the facility.The facility did not ensure food prep areas and equipment were in clean and sanitary condition.The facility did not have internal thermometers in the reach-in cooler and walk-in freezer to accurately monitor temperatures.Findings include:Food Prep Areas/Equipment: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours.The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Non-food contact surfaces… […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2022

  Based on observation, staff interviews, and record review, the facility did not ensure food was stored and served under sanitary conditions. The practices had the potential to affect all 27 residents. Facility did not maintain freezer to prevent build-up of ice descending from condenser unit onto box of lasagna noodles and shelving. Facility did not ensure Certified Nursing Assistant (CNA)-J was trained when to wash hands while processing dishes through dishwashing machine. Findings include: On 8/16/22, Dietary Manager (DM)-G indicated the facility utilized the Wisconsin (WI) Food Code as its standard of practice. Freezer WI Food Code 2020 documents at 4-501.11(A) Equipment shall be maintained in a state of repair . […]

• No harm, potential for more than minimal, widespreadF812Jul 8, 2021

  Based on observation, staff interviews, and record review, the facility did not store, prepare, and serve food under sanitary conditions. These practices had the potential to effect all 28 residents at the facility. The facility's kitchen hand washing sink, kitchen reach-in refrigerator, conventional ovens, convection oven, and dining room reach in refrigerator were soiled. The facility's walk in freezer had a build-up of ice from fan/condenser unit, down all shelves at back of freezer with boxes frozen in place and a pool of ice at the floor under the fan/condenser unit. The facility did not have a practice of monitoring and documenting holding temperatures. […]

• No harm, potential for more than minimal, patternF645Mar 19, 2026

  Based on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 4 residents (R) (R23, R37, R1, and R6) of 5 sampled residents.The facility did not contact the state mental health authority when R23, R37, R1, and R6's PASRR Level I 30-day exemption expired or pursue further PASRR Level II screening.Findings include: The facility's Resident Assessment: Coordination with PASARR Program policy, dated [DATE], indicates: This facility coordinates assessments with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs .ii. […]

• No harm, potential for more than minimal, patternF809Mar 19, 2026

  Based on observation, staff and resident interview, and record review, the facility did not ensure meals were served at regular times and in accordance with residents' preferences. This practice had the potential to affect more than 4 of the 42 residents residing in the facility.The facility consistently served meals later than posted mealtimes and residents' preferences.Findings include:On 3/17/26, Surveyor observed a document titled Meal Times posted in the dining room and outside the activity room that indicated the following: ~ Breakfast: 8:30 AM - Dining room; 8:45 AM - Room trays~ Lunch: 12:30 PM - Dining room; 12:45 PM - Room trays~ Dinner - 5:30 PM - Dining room; 5:45 PM - Room traysOn 3/17/26, Surveyor observed lunch in the dining room which started at 1:05 PM. […]