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Complaint Investigation

Edenbrook Sheboygan

September 3, 2025 · Sheboygan, WI · 3014 Erie Ave
Citations 1
CMS Rating 1/5
Beds 121
Provider ID 525568
Healthcare Facility
Edenbrook Sheboygan
Sheboygan, WI  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0605
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Sheboygan, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Edenbrook Sheboygan or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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