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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