Deficiency Records for Sheboygan Health Services
Updated as of October 01, 2021
This is not the most recent data for Sheboygan Health Services. For the most recent information, click here.
A list of the most recent deficiencies for Sheboygan Health Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-07-09 | 2022-01-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-09 | 2022-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-09 | 2021-08-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-09 | 2021-08-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-07-09 | 2021-08-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-09 | 2021-08-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-09 | 2021-08-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-09 | 2021-08-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-09 | 2021-08-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-08 | 2021-08-04 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-07-08 | 2021-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-08 | 2021-08-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-08 | 2021-08-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-09 | 2021-03-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-09 | 2021-03-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-12 | 2020-04-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-03-12 | 2020-04-12 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-20 | 2019-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-20 | 2019-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-20 | 2019-07-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-18 | 2019-07-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-18 | 2019-07-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-06-18 | 2019-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-18 | 2019-07-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-18 | 2019-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-18 | 2019-07-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-18 | 2019-07-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-04 | 2019-06-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-18 | 2018-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-18 | 2018-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-18 | 2018-05-19 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2018-04-19 | 2018-05-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-19 | 2018-05-19 | N |
| 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. | Health | 2018-04-19 | 2018-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-19 | 2018-05-19 | N |
