Sheboygan Senior Community Inc

In the surveyor’s words

From the most serious findings on record at Sheboygan Senior Community Inc, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 20, 2026

  Based 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). […]

• No harm, potential for more than minimal, widespreadF812Jan 20, 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 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. Findings include: On 1/13/26 at 2:09 PM, Surveyor interviewed Dietary Manager (DM)-R who stated the facility follows the Wisconsin Food Code. Microwave Cleanliness: The Wisconsin Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. […]

• No harm, potential for more than minimal, widespreadF801Sep 25, 2024

  Based 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. Findings include: On [DATE] at 9:04 AM, Surveyor interviewed DM-H who indicated DM-H worked in the facility for several years and had been the Dietary Manager for 3 to 4 years. DM-H indicated DM-H was ServSafe certified; however, DM-H's certification expired in August and DM-H had not renewed it. […]

• No harm, potential for more than minimal, widespreadF812Sep 25, 2024

  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 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. […]

• No harm, potential for more than minimal, widespreadF868Sep 25, 2024

  Based 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. Findings include: On 9/24/24, Surveyor requested the facility's policy and procedure for Quality Assurance and Performance Improvement (QAPI). Director of Nursing (DON)-B provided Surveyor with an undated QAPI Plan which was worded in the style of a template and did not describe the facility's specific QAPI policy and procedure. […]