Cycle 1
Health 2025-05-29 · Fire 2025-05-29
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Seymour, WI
Good Shepherd Services Ltd
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
607 Bronson Rd, Seymour, WI
(920) 833-6856
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
0.78
Licensed practical nurse staffing
Aide hours / resident day
2.77
Nurse aide staffing
Weekend hours
3.68
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
95.7%
3.8 pts worse
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.9%
About the same
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
16.6%
4.6 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
16.7%
5.5 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
17.3%
1.8 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
3.0%
2 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
25.5%
1.7 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.5%
2.8 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
86.8%
0.2 pts worse
|
81.7%
4.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
82.2%
8.2 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-29
F · Potential for more than minimal harm
2025-05-29
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-06-29
F · Potential for more than minimal harm
2025-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-29
F · Potential for more than minimal harm
2024-04-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-11
F · Potential for more than minimal harm
2024-04-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-11
F · Potential for more than minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-11
E · Potential for more than minimal harm
2024-04-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-11
E · Potential for more than minimal harm
2023-04-19
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-29
D · Potential for more than minimal harm
2025-05-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-29
C · Minimal harm
2025-05-29
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-06-29
D · Potential for more than minimal harm
2024-04-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-11
D · Potential for more than minimal harm
2023-04-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-08
Penalties and ownership
What sits behind the stars
Ownership
Gilliam, Dawn
Corporate Director · Individual
Hartig, Donald
Operational/Managerial Control · Individual
Katch, Jean
Operational/Managerial Control · Individual
Katch, Jean
Corporate Director · Individual
Mcclone, Karla
Operational/Managerial Control · Individual
Mcclone, Karla
Corporate Director · Individual
Piehl, Cayla
Operational/Managerial Control · Individual
Rickert, Lisa
Operational/Managerial Control · Individual
Rickert, Lisa
Corporate Director · Individual
Rickert, Lisa
Corporate Officer · Individual
Schroeder, Todd
Operational/Managerial Control · Individual
Schroeder, Todd
Corporate Director · Individual
Schroeder, Todd
Corporate Officer · Individual
Walters, Joel
Operational/Managerial Control · Individual
Walters, Joel
Corporate Director · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Zahn, Joyce
Operational/Managerial Control · Individual
Zahn, Joyce
Corporate Director · Individual
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
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#3
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