Federal inspection record · CMS data as of October 1, 2026
Sheboygan Senior Community Inc
3505 County Road Y, Sheboygan, WI · (920) 458-2137
- Certified beds
- 60
- Residents per day
- 60
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- October 1, 1996
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Sheboygan Senior Community Inc carries 115 inspection points. That is fewer than 26% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
29 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Everything else, by area of care
Resident Rights8E
- E
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
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.
Quality of Life and Care5D
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide enough food/fluids to maintain a resident's health.
Nutrition and Dietary3F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control3F
- F
Provide and implement an infection prevention and control program.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- F
Provide and implement an infection prevention and control program.
Pharmacy Service3E
- E
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.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
Resident Assessment and Care Planning2D
- D
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Administration2F
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- D
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.
Inspection history
2026-01-20
10 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2024-09-25
17 health deficiencies · 8 fire-safety deficiencies
Top issue: Resident Rights (5 deficiencies)
2023-07-19
2 health deficiencies · 7 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 4 h 3 min of nursing staff time a day, 17 min of it from a registered nurse.
This home
4 h 3 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 37% of nursing staff and 40% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.1 pts worse | 2.7 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.7 pts better | 1.5 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.5 pts better | 98.5% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.2 pts worse | 94.4% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.3 pts better | 2.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.1 pts better | 3.9% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.2 pts better | 4.7% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication4.8 pts worse | 21.6% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.4 pts better | 13.5% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened16.4 pts worse | 33.4% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased13.3 pts worse | 29.1% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder2.3 pts worse | 4.2% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection5.4 pts worse | 8.1% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.2 pts worse | 24.8% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.3 pts worse | 6.2% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine6.2 pts better | 93.1% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit6.9 pts better | 8.7% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.4 pts better | 0.8% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine26.6 pts worse | 55.6% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission6.1 pts better | 16.4% | 22.5% | 23.4% |
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Who owns and runs it
19 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bank First National | 5% Or Greater Mortgage Interest · Organization | 0% | 1 facilities |
| Clapp, Roger | Corporate Director · Individual | 0% | 1 facilities |
| Fritz, Perry | Corporate Director · Individual | 0% | 1 facilities |
| Gensch, Brian | Corporate Director · Individual | 0% | 1 facilities |
| Hamer, Stephen | Corporate Director · Individual | 0% | 1 facilities |
| Holzem, Tara | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Houwers, James | Corporate Director · Individual | 0% | 1 facilities |
| Houwers, James | Corporate Officer · Individual | 0% | 1 facilities |
| Isken, Keith | Corporate Director · Individual | 0% | 1 facilities |
| Kerpe, Marsha | Corporate Director · Individual | 0% | 1 facilities |
| Price, James | Corporate Director · Individual | 0% | 1 facilities |
| Theune, Doris | Corporate Director · Individual | 0% | 1 facilities |
| Theune, Doris | Corporate Officer · Individual | 0% | 1 facilities |
| Thompson, Cynthia | Corporate Director · Individual | 0% | 2 facilities |
| Trager, Margaret | Corporate Director · Individual | 0% | 1 facilities |
| Treffert, Paul | Operational/Managerial Control · Individual | 0% | 1 facilities |
| United States Department Of Agriculture - Rural Development | 5% Or Greater Mortgage Interest · Organization | 0% | 3 facilities |
| Vandewater, David | Corporate Director · Individual | 0% | 1 facilities |
| Vandewater, David | Corporate Officer · Individual | 0% | 1 facilities |
·
Fire safety
22 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke7E
- E
Provide properly protected cooking facilities.
- C
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems5F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have proper medical gas storage and administration areas.
- E
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
- D
Meet requirements for the use of electrical equipment.
Services4F
- F
Have properly installed electrical wiring and gas equipment.
- D
Install properly constructed and protected linen or trash chutes.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Install properly constructed and protected linen or trash chutes.
Miscellaneous3F
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have simulated fire drills held at unexpected times.
Emergency Preparedness2F
- F
Develop Emergency Preparedness policies and procedures.
- F
Conduct testing and exercise requirements.
Construction1E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
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Other homes nearby
-
Sheboygan Health Services
Sheboygan, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 12 min
- Fines
- $0
-
Edenbrook Sheboygan
Sheboygan, WI · Eden Senior Care
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 13 min
- Fines
- $345,576
-
Morningside Health Services
Sheboygan, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 56 min
- Fines
- $0