Sheboygan Senior Community INC

Inspection findings

1. Jan 20, 2026 Fire Safety · 16 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 18, 2026 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 16, 2026 · CMS fire safety

2. Feb 27, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 26, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Mar 26, 2025 · CMS health inspection

3. Sep 25, 2024 Fire Safety · 23 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Oct 11, 2024 · CMS fire safety

   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0553 Resident Rights Deficiencies

     Allow resident to participate in the development and implementation of his or her person-centered plan of care.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0623 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.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0625 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.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 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.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0758 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.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0801 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.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0840 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.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 21, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Oct 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Nov 8, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Oct 14, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Oct 2, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Oct 15, 2024 · CMS fire safety

4. Jul 19, 2023 Health · 9 findings
   • Not serious Scope/severity D

     F0758 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.

     Corrected Aug 10, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jul 20, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Aug 3, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Jul 24, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Aug 9, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Sep 27, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Aug 8, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Aug 25, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CLAPP, ROGER — corporate director, NOT APPLICABLE, since 07/01/2011
• FRITZ, PERRY — corporate director, NOT APPLICABLE, since 07/01/2014
• GENSCH, BRIAN — corporate director, NOT APPLICABLE, since 05/01/2017
• HAMER, STEPHEN — corporate director, NOT APPLICABLE, since 07/01/2011
• HOLZEM, TARA — w-2 managing employee, NOT APPLICABLE, since 05/24/2014
• HOUWERS, JAMES — corporate officer, NOT APPLICABLE, since 07/01/2011
• HOUWERS, JAMES — corporate director, NOT APPLICABLE, since 07/01/2011
• ISKEN, KEITH — corporate director, NOT APPLICABLE, since 05/01/2017
• KERPE, MARSHA — corporate director, NOT APPLICABLE, since 07/01/2011
• PRICE, JAMES — corporate director, NOT APPLICABLE, since 07/01/2011
• THEUNE, DORIS — corporate officer, NOT APPLICABLE, since 07/01/2011
• THEUNE, DORIS — corporate director, NOT APPLICABLE, since 07/01/2011
• THOMPSON, CYNTHIA — corporate director, NOT APPLICABLE, since 07/01/2015
• TRAGER, MARGARET — corporate director, NOT APPLICABLE, since 05/01/2017
• TREFFERT, PAUL — operational/managerial control, NOT APPLICABLE, since 03/01/2016
• VANDEWATER, DAVID — corporate director, NOT APPLICABLE, since 07/01/2014
• VANDEWATER, DAVID — corporate officer, NOT APPLICABLE, since 07/01/2014
• BANK FIRST NATIONAL — 5% or greater mortgage interest, NOT APPLICABLE, since 02/26/2010
• UNITED STATES DEPARTMENT OF AGRICULTURE - RURAL DEVELOPMENT — 5% or greater mortgage interest, NOT APPLICABLE, since 12/01/2016