B80

SHEBOYGAN SENIOR COMMUNITY INC

Grade B 80/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
4/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

60

Ownership

Non profit - Corporation

Total Fines

None

Last Survey

N/A

3505 COUNTY ROAD Y, SHEBOYGAN, WI 53083
9204582137

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.33h
LPN
1.07h
CNA
3.15h
Total
4.56h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

THEUNE, DORIS

IndividualCORPORATE OFFICERSince Jul 2011

TREFFERT, PAUL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2016

CLAPP, ROGER

IndividualCORPORATE DIRECTORSince Jul 2011

FRITZ, PERRY

IndividualCORPORATE DIRECTORSince Jul 2014

GENSCH, BRIAN

IndividualCORPORATE DIRECTORSince May 2017

HAMER, STEPHEN

IndividualCORPORATE DIRECTORSince Jul 2011

HOUWERS, JAMES

IndividualCORPORATE DIRECTORSince Jul 2011

ISKEN, KEITH

IndividualCORPORATE DIRECTORSince May 2017

KERPE, MARSHA

IndividualCORPORATE DIRECTORSince Jul 2011

PRICE, JAMES

IndividualCORPORATE DIRECTORSince Jul 2011

THEUNE, DORIS

IndividualCORPORATE DIRECTORSince Jul 2011

THOMPSON, CYNTHIA

IndividualCORPORATE DIRECTORSince Jul 2015

TRAGER, MARGARET

IndividualCORPORATE DIRECTORSince May 2017

VANDEWATER, DAVID

IndividualCORPORATE DIRECTORSince Jul 2014

HOUWERS, JAMES

IndividualCORPORATE OFFICERSince Jul 2011

VANDEWATER, DAVID

IndividualCORPORATE OFFICERSince Jul 2014

HOLZEM, TARA

IndividualW-2 MANAGING EMPLOYEESince May 2014

BANK FIRST NATIONAL

Organization5% OR GREATER MORTGAGE INTERESTSince Feb 2010

UNITED STATES DEPARTMENT OF AGRICULTURE - RURAL DEVELOPMENT

Organization5% OR GREATER MORTGAGE INTERESTSince Dec 2016

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (28)

February 27, 2025Health2 deficiencies
0609DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 26, 2025
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 26, 2025
September 25, 2024Health15 deficiencies
0550EMinimal harm, Pattern

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

Resident Rights Deficiencies

Corrected Nov 8, 2024
0553DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Nov 8, 2024
0582DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Nov 8, 2024
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Nov 8, 2024
0625DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Nov 8, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 8, 2024
0692DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 8, 2024
0757DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Nov 8, 2024
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Nov 8, 2024
0801FMinimal harm, Widespread

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.

Nutrition and Dietary Deficiencies

Corrected Nov 8, 2024
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Nov 8, 2024
0840DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Nov 8, 2024
0868FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Nov 8, 2024
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 8, 2024
0882FMinimal harm, Widespread

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

Infection Control Deficiencies

Corrected Nov 8, 2024
July 19, 2023Health2 deficiencies
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Aug 10, 2023
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 9, 2023
June 29, 2022Health9 deficiencies
0578DMinimal harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Jul 29, 2022
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 29, 2022
0623CNo harm, Widespread

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Jul 29, 2022
0625CNo harm, Widespread

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.

Resident Rights Deficiencies

Corrected Jul 29, 2022
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 29, 2022
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Jul 29, 2022
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 29, 2022
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 29, 2022
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jul 29, 2022

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Frequently Asked Questions

What is the CareGrader rating for SHEBOYGAN SENIOR COMMUNITY INC?

SHEBOYGAN SENIOR COMMUNITY INC in SHEBOYGAN, Wisconsin has a CareGrader grade of B (Good), with a composite score of 80.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for SHEBOYGAN SENIOR COMMUNITY INC?

SHEBOYGAN SENIOR COMMUNITY INC has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does SHEBOYGAN SENIOR COMMUNITY INC have?

SHEBOYGAN SENIOR COMMUNITY INC has 28 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does SHEBOYGAN SENIOR COMMUNITY INC have?

SHEBOYGAN SENIOR COMMUNITY INC has 60 certified beds with approximately 57 current residents (95% occupancy). The facility is located at 3505 COUNTY ROAD Y, SHEBOYGAN, Wisconsin 53083. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.