Sheboygan Senior Community INC
3505 County Road Y, Sheboygan, WI 53083 · Sheboygan County · 60 certified beds · avg 56 residents/day · certified since Oct 1, 1996
2/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
4.52
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jan 20, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 10, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 20, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 20, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 25, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 25, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Sep 25, 2024 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
| Jul 19, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 19, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (15 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | F |
| 2024 | 15 | 0 | F |
| 2025 | 2 | 0 | D |
| 2026 | 9 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.52 | 4.29 | 3.95 | top 34% in Wisconsin; top 23% in the U.S. |
| Registered Nurse hours | 0.31 | 1.01 | 0.69 | bottom 1% in Wisconsin; bottom 10% in the U.S. |
| Weekend total nurse staffing | 4.29 | 3.84 | 3.50 | top 27% in Wisconsin; top 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.11 | 0.68 | 0.48 | bottom 1% in Wisconsin; bottom 2% in the U.S. |
| Total nursing staff turnover (%) | 36.8 | 46.9 | 45.8 | top 22% in Wisconsin; top 28% in the U.S. |
| RN turnover (%) | 0.0 | 39.7 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.26, RN 0.29, weekend 4.04. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 1/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bank First National | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 02/26/2010 |
| Clapp, Roger | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Fritz, Perry | Individual | Corporate Director | NOT APPLICABLE | 07/01/2014 |
| Gensch, Brian | Individual | Corporate Director | NOT APPLICABLE | 05/01/2017 |
| Hamer, Stephen | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Holzem, Tara | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/24/2014 |
| Houwers, James | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Houwers, James | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2011 |
| Isken, Keith | Individual | Corporate Director | NOT APPLICABLE | 05/01/2017 |
| Kerpe, Marsha | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Price, James | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Theune, Doris | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Theune, Doris | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2011 |
| Thompson, Cynthia | Individual | Corporate Director | NOT APPLICABLE | 07/01/2015 |
| Trager, Margaret | Individual | Corporate Director | NOT APPLICABLE | 05/01/2017 |
| Treffert, Paul | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2016 |
| United States Department of Agriculture - Rural Development | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/01/2016 |
| Vandewater, David | Individual | Corporate Director | NOT APPLICABLE | 07/01/2014 |
| Vandewater, David | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sheboygan Health Services | 2.3 mi | Sheboygan, WI | ★★★☆☆ | 3/5 | |
| Edenbrook Sheboygan | 2.6 mi | Sheboygan, WI | ★☆☆☆☆ | 1/5 | |
| Morningside Health Services | 2.9 mi | Sheboygan, WI | ★★★☆☆ | 4/5 | |
| Sheboygan Progressive Health Services | 4.5 mi | Sheboygan, WI | ★☆☆☆☆ | 2/5 | |
| Meadow View Health Services | 5.3 mi | Sheboygan, WI | ★★★★☆ | 3/5 | |
| Plymouth Health Services | 9.9 mi | Plymouth, WI | ★☆☆☆☆ | 2/5 | |
| Rocky Knoll Health Care | 10.0 mi | Plymouth, WI | ★★★☆☆ | 3/5 | |
| Willowdale Health Services | 18.6 mi | New Holstein, WI | ★★★☆☆ | 4/5 | |
| Homestead Health Services | 19.3 mi | New Holstein, WI | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525598.