7 Reports
Inspection Report — Apr 7, 2026
Follow-Up State
Date: Apr 7, 2026
Visit Reason
Surveyors conducted a verification visit and three complaint investigations at Aura Memory Care of Sheboygan 19.
Complaint Details
Three complaints were investigated and found to be unsubstantiated.
Findings
Previous violations have been corrected, three complaints were unsubstantiated, and no new deficiencies were identified.
Report Facts
Revisit fee: 200
Inspection Report — Jan 26, 2026
Complaint Investigation State
Date: Jan 26, 2026
Visit Reason
A complaint investigation was conducted to determine if Azura Memory Care of Sheboygan 19 was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, resulting in a Statement of Deficiency and enforcement action.
Findings
The Department issued a Statement of Deficiency for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to protect residents' rights and ensure dignity, respect, and individuality in a homelike environment.
Deficiencies (1)
Wis. Admin. Code § DHS 83.32(3)(L): The facility failed to ensure residents' rights to make decisions related to care, activities, and daily routines were protected and promoted. Restrictions on residents' freedom of choice were imposed without documented treatment plans based on clinical or therapeutic indications.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
Posting duration: 90
Appeal filing timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report — Jan 14, 2026
Complaint Investigation State
Date: Jan 14, 2026
Visit Reason
The inspection was conducted as a complaint investigation following a complaint alleging improper request for supervision of Resident 1.
Complaint Details
One complaint was substantiated related to improper request for supervision of Resident 1, resulting in one deficiency.
Findings
The provider did not ensure Resident 1's right to the least restrictive environment was honored, as Resident 1 was placed on 1:1 staffing and had a door alarm on the room without updated assessment or individual service plan reflecting these restrictions.
Deficiencies (1)
83.32(3)(l) Rights of Residents: Least restrictive environment was not met as Resident 1 was placed on 1:1 staffing 24/7 and had a door alarm without updated assessment or individual service plan.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HS A | House Supervisor | Provided information about Resident 1's 1:1 staffing and behavior |
| CG B | Caregiver | Interviewed regarding Resident 1's behaviors and 1:1 staffing |
| RN C | Registered Nurse | Interviewed about Resident 1's behaviors and care |
| ADM D | Administrator | Interviewed about 1:1 staffing and family involvement |
| Regional E | Regional Representative | Interviewed regarding assessment and privacy concerns for Resident 1 |
Inspection Report — Jun 27, 2025
Complaint Investigation State
Date: Jun 27, 2025
Visit Reason
Surveyor conducted one complaint investigation at Azura Memory Care of Sheboygan 19.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report — Aug 19, 2024
Complaint Investigation State
Date: Aug 19, 2024
Visit Reason
Surveyor reviewed 3 complaints at the facility.
Complaint Details
Three complaints were unsubstantiated.
Findings
Three complaints were reviewed and all were found to be unsubstantiated with no new deficiencies identified.
Report Facts
Complaints reviewed: 3
Inspection Report — Jun 13, 2023
Complaint Investigation State
Date: Jun 13, 2023
Visit Reason
The surveyor conducted a standard survey and complaint investigation at Azura Memory Care Sheboygan 19, a Community-Based Residential Facility (CBRF), to assess compliance and investigate a complaint.
Complaint Details
Complaint was investigated and found to be unsubstantiated. The odor was attributed to a former resident who urinated throughout the building and had behaviors that made incontinence care difficult.
Findings
One deficiency was identified related to the facility not ensuring a clean and homelike living environment due to a strong odor of urine observed in multiple areas of the building. The complaint was unsubstantiated.
Deficiencies (1)
The provider did not ensure a clean and homelike living environment as evidenced by a strong odor of urine in the entryway, hallway with rooms 10-18, resident room 14, and bathroom on the hallway with rooms 10-18.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Interviewed about the strong odor of urine and resident behaviors contributing to the odor. | |
| Executive Director A | Executive Director | Interviewed about the odor concerns and acknowledged the issue, stating maintenance would be contacted to correct it. |
Notice — Jun 13, 2023
State
Date: Jun 13, 2023
Visit Reason
A standard survey and complaint investigation were conducted on June 13, 2023, to determine if Azura Memory Care of Sheboygan 19 was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #B4QB11) for violations of Wisconsin Statutes and Administrative Codes related to the operation of the facility, requiring the licensee to comply with all requirements within 45 days.
Report Facts
Days to achieve compliance: 45
Appeal filing period: 10
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
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