Edenbrook Sheboygan
Edenbrook Sheboygan in Sheboygan, WI — inspection on September 3, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the wheelchair because R2 attempts to get out of the wheelchair. ADON-H indicated R2 was in a Broda chair supplied by the facility during R2's last fall. ADON-H indicated R2's POAHC does not want R2 in a wheelchair since R2 has fallen out of a wheelchair. ADON-H indicated the facility does not have a signed risks versus benefits statement regarding getting R2 up in a wheelchair and indicated ADON-H had R2 in a wheelchair for dinner last night which was not documented. ADON-H stated RN-C contacted the Hospice NP for a Haldol order and indicated R2's behavior has not changed since Haldol was started. ADON-H indicated R1 refused to take medication on 9/2/25 and R2's Haldol order was increased to 2 mg every 6 hours for restlessness and agitation.
When Surveyor asked about documentation that indicated R2 ambulates, ADON-H indicated R2 has not ambulated in the 5 months ADON-H has been employed.
ADON-H indicated R2 is up in a wheelchair 3 to 4 times a week but it is not documented. On 9/3/25 at 4:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R2's POAHC does not want R2 out of bed. NHA-A indicated the facility should have obtained a risks versus benefits statement for R2.
NHA-A also indicated non-pharmacological interventions should be reviewed, updated, and added to R2's care plan.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.