Edenbrook Sheboygan: Care Plan Failures Put Resident at Risk - WI
That was one of several admissions federal inspectors pulled from staff at Edenbrook Sheboygan during a September 3 complaint inspection. What emerged was a picture of a facility making significant decisions about a vulnerable resident's care, then leaving almost no record that any of it happened.
The resident, identified in inspection records only as R2, is a hospice patient. R2's power of attorney for health care had told the facility clearly: do not put R2 in a wheelchair. R2 had fallen out of one before. The family's position was documented. The facility's response, according to the assistant director of nursing, identified in records as ADON-H, was to keep putting R2 in a wheelchair anyway — for dinner, among other occasions — without obtaining a signed risks versus benefits statement and without charting it.
ADON-H told the surveyor that R2 had been in a Broda chair, a type of reclining wheelchair supplied by the facility, at the time of R2's last fall. That detail made the family's concern more than precautionary. It was grounded in what had already happened to this person, in this building, in this kind of chair.
When the surveyor asked about documentation showing R2 could walk, ADON-H said R2 had not ambulated in the five months ADON-H had been employed at the facility.
The wheelchair wasn't the only thing going undocumented. R2 had been prescribed Haldol, an antipsychotic medication used here for restlessness and agitation. A nurse identified as RN-C had contacted a hospice nurse practitioner to obtain the order. ADON-H told inspectors the medication hadn't changed R2's behavior since it was started. On September 2, the day before the inspection, the Haldol dose was increased to 2 milligrams every six hours.
That increase came on the same day R2 refused to take medication. The inspection record notes the refusal in the same sentence as the dose increase, without further explanation of the connection.
ADON-H acknowledged the facility had no signed risks versus benefits statement for getting R2 up in a wheelchair. That form exists to document that a resident or their representative has been told what could go wrong and has agreed to proceed anyway. Without it, the facility was making a repeated physical intervention that the family opposed, without any formal record that the risks had been weighed or communicated.
The nursing home administrator, identified as NHA-A, was interviewed at 4:00 PM on the day of the inspection. NHA-A's account added a wrinkle: the facility's understanding, at least at the administrative level, was that R2's power of attorney did not want R2 out of bed at all. That is a stricter position than simply avoiding wheelchairs. If accurate, it means the facility's practice of wheelchair transfers several times a week was not just undocumented, it was contrary to the family's explicit instructions.
NHA-A acknowledged the facility should have obtained a risks versus benefits statement. NHA-A also said non-pharmacological interventions for R2's restlessness and agitation should be reviewed, updated, and added to the care plan. That statement, offered the afternoon inspectors arrived, implied the care plan as it existed that day did not adequately address those interventions.
The inspection cited the facility under F0605, which covers care planning obligations for residents. The level of harm was listed as minimal harm or potential for actual harm.
What the record shows is a hospice patient, someone whose medical trajectory is already defined, being moved in and out of a chair that contributed to a prior fall, without the family's consent, without documentation, and without a care plan that reflected what was actually being done. The sedative prescribed for agitation was increased the same week the family's directives appear to have been disregarded.
NHA-A said the right things when the surveyor asked. The risks versus benefits form should have been obtained. The care plan should have been updated. Non-pharmacological approaches should have been considered.
None of that had happened before someone filed a complaint and inspectors walked through the door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenbrook Sheboygan from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Edenbrook Sheboygan in Sheboygan, WI was cited for violations during a health inspection on September 3, 2025.
That was one of several admissions federal inspectors pulled from staff at Edenbrook Sheboygan during a September 3 complaint inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.