Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eden Rehab Suites And Green House Homes during CMS and state inspections, most recent first.
A resident with intact cognition and a history of acute and chronic respiratory failure with hypoxia and COPD requested a copy of their medical record in writing, with a family member also involved in the request. The NHA received the email requests and indicated the facility had up to 30 days to respond, while the SW was unsure of the required timeframe. The DON reported there was no specific policy for handling medical record requests. Although the NHA had a paper copy of the record and was planning an internal review meeting before release, the resident had not received the requested records within the required timeframe, resulting in a deficiency for failure to provide timely access to medical records.
A hospice patient with metastatic cancer, chronic pain, and a stage 4 pressure ulcer repeatedly reported pain at 9–10/10, became verbally aggressive, and requested IV pain medication that the facility could not provide. Staff believed the resident had received the maximum scheduled and PRN pain medications and, after the resident agreed to go to the hospital, an RN notified the DON and arranged transfer to the ER without first notifying hospice, and did not initially notify the POAHC. The hospice agency later reported it had not been informed of the resident’s escalating pain or behavior before the day the resident was sent to the ER, and stated the resident’s pain regimen could have been adjusted.
Two residents were transferred to the hospital and did not receive proper written bed-hold and transfer/discharge notices with required appeal rights information. One resident with metastatic cancer, chronic pain, a stage 4 pressure ulcer, and moderate cognitive impairment, represented by an activated POA, was told by the admissions staff that the resident was being kicked out and would not be allowed to return, and neither the resident nor the POA received any written bed-hold or transfer/discharge notice. Another resident with acute on chronic combined systolic and diastolic CHF and aspiration pneumonia, who was cognitively intact and made their own healthcare decisions, signed a bed-hold/transfer form that lacked mandated appeal rights details, including contact information for the appeals entity and instructions on obtaining and submitting an appeal. The DON acknowledged that the facility used the bed-hold form as its policy, had no separate policy, and was unaware of the requirement to include appeal rights on these notices.
Staff failed to follow facility policy and MD orders for respiratory care when a resident with COPD, acute and chronic respiratory failure with hypoxia, acute pulmonary edema, and heart failure received nebulizer treatments. Although the MAR showed that nebulizer treatments were given and the resident self-administered them after nurse set-up, nursing staff did not consistently assess or document required pre- and post-treatment parameters such as lung sounds, pulse, respirations, and oxygen saturation as directed. The DON confirmed that nebulizer assessments should be documented on the MAR and that this was not consistently done for this resident.
A hospice resident with metastatic cancer, chronic pain, and opioid dependence experienced uncontrolled pain rated 10/10 despite having both scheduled and PRN morphine and adjunctive medications ordered. CNAs and the DON reported the resident repeatedly requested pain medication, exhibited distress and behavioral changes, and refused some non-pharmacologic interventions and assessments. The RN administered scheduled and one PRN morphine dose, documented it as effective despite ongoing aggressive behavior, and reported offering additional PRN morphine later, but the medical record showed no documentation of further offers or refusals and confirmed that more PRN morphine could have been given before the resident was transferred. Facility staff told hospice and the hospital that the resident had “maxed out” on pain medications and was being sent to the ER for uncontrolled pain and behavior, while hospice reported the resident had not reached maximum dosing and that the facility declined hospice’s offer to assess and adjust the pain regimen before transfer.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen, including a microwave with dried food debris, improperly stored and outdated food items in the refrigerator, and a dishwasher that did not reach the required sanitizing temperature. These deficiencies were observed during a kitchen inspection and had the potential to affect all residents.
Two residents with activated POAHC due to incapacity had healthcare decisions made or consents signed by individuals not authorized as their healthcare agents. In one case, a family member not listed in the POAHC made decisions, and in another, the incapacitated resident signed their own medical consents instead of the designated agent. Staff confirmed these actions were not in accordance with facility policy or state law.
A resident with Alzheimer's disease, moderate cognitive impairment, and mobility needs was repeatedly observed with their call light out of reach while in bed. The resident was unable to access the call light when needing assistance, and staff confirmed the device was not accessible as required by facility policy.
The facility did not ensure timely and accurate completion of PASRR Level I and Level II screenings or obtain required county exemption forms for three residents with mental illness diagnoses and/or prescribed psychotropic medications. PASRR documentation was not updated to reflect medication changes, and necessary screenings were not submitted when residents remained in the facility beyond 30 days.
Two residents did not receive timely and appropriate assistance with ADLs. One resident with a large perirectal wound was left in urine or stool for extended periods due to delayed call light response and inadequate incontinence care, while another resident discharged from PT did not receive the recommended restorative ambulation program, with staff unaware of the walking schedule and the care plan lacking this intervention. Facility policies requiring timely response and maintenance of ADL abilities were not followed.
Multiple residents with cognitive impairment and a history of falls experienced repeated unwitnessed falls without thorough investigation, root cause analysis, or updates to their care plans. Required neurological checks were often incomplete or missing, and the facility did not consistently follow its own fall procedures. The DON confirmed that fall investigations, care plan updates, and neuro checks were not properly completed after these incidents.
Surveyors observed that two residents with indwelling medical devices did not receive care in accordance with infection control and Enhanced Barrier Precautions (EBP) policies. During perineal care, staff failed to perform hand hygiene between glove changes, did not wear required gowns, and did not ensure EBP signage or PPE carts were present. Staff and nursing leadership confirmed these actions did not meet facility policy requirements.
The facility failed to complete ordered wound care for two residents, leading to immediate jeopardy for one. A resident with Charcot's foot did not receive daily dressing changes, resulting in maggots in the wound and hospital transfer. Another resident's dressing change was missed, with no documentation of completion. The deficiencies were due to lapses in following prescribed wound care regimens.
The facility did not ensure food was stored and prepared in a sanitary manner, with items in the kitchen cooler not listed on the cooling log and kitchenettes found in unsanitary conditions. The Dietary Manager confirmed that the facility's process for documenting food cooling temperatures and daily cleaning of kitchenettes was not being followed.
A resident with severe cognitive impairment and multiple diagnoses experienced several falls resulting in injuries due to the facility's failure to implement fall prevention interventions as outlined in the care plan. Observations revealed the bed was not in the lowest position and the floor mat was not in place, despite these measures being required.
Failure to Provide Timely Access to Requested Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to a resident’s medical record after a written request. A resident with intact cognition, as evidenced by a BIMS score of 15/15 on an MDS assessment dated 12/10/25, had been admitted with diagnoses including acute and chronic respiratory failure with hypoxia and COPD with acute exacerbation, and was discharged on 12/10/25. The resident and a family member submitted a written request for the resident’s medical record to the Nursing Home Administrator via email on 1/20/26, followed by a signed formal request sent via email on 1/22/26. As of 2/5/26, the resident had not received the requested records. The family member reported that the NHA responded by email stating the facility had up to 30 days to provide the records. During interviews, the DON stated the facility did not have a policy for medical record requests and instead followed state and federal regulations. The Social Worker acknowledged awareness of the resident’s request but was uncertain of the required timeframe for releasing records, estimating it to be 48 hours. The NHA showed the surveyor a paper copy of the resident’s medical record and stated that a meeting to review the records, originally planned for 2/4/26, had been postponed to 2/6/26, and that the NHA intended to call the resident after the meeting to inform them the records were ready for pickup. Despite the request and internal awareness of it, the records had not been provided to the resident within the required timeframe, resulting in the deficiency related to timely access to medical records.
Failure to Notify Hospice of Uncontrolled Pain Prior to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a hospice agency in a timely manner about a resident’s uncontrolled pain and escalating behavior. The resident was admitted on hospice services with multiple serious diagnoses, including metastatic prostate cancer to the bone, a stage 4 right heel pressure ulcer, osteomyelitis, cervical radiculopathy, chronic pain, peripheral neuropathy, and opioid dependence. The resident’s cognition was assessed as modified independent, and a Power of Attorney for Healthcare (POAHC) had been activated. Staff interviews and record review showed that the resident repeatedly reported pain at 9–10 out of 10, requested IV pain medication that the facility could not provide, and became verbally aggressive and impatient with call light response times. The Admissions Coordinator reported being informed that the resident had “maxed out” on pain medications and still had pain at 10 out of 10, and stated that hospice and family were notified that the resident’s pain remained uncontrolled and that the resident was requesting more pain medication than the facility could provide. However, the Hospice Director of Clinical Services stated hospice had not received any reports of uncontrolled pain or escalating verbally aggressive behavior prior to the morning when the Nursing Home Administrator and Admissions Coordinator informed hospice that the resident’s pain was 9–10 out of 10 and that the resident was being sent to the ER. The Hospice Director also stated the resident had not actually “maxed out” on pain medication and that medications could have been adjusted. The DON reported that the RN had given all pain medication the resident could have per facility understanding, found it ineffective, notified the on-call provider, and sent the resident to the ER, but could not recall if hospice was contacted before the transfer. The RN confirmed not notifying hospice prior to sending the resident to the hospital, stating the resident’s mind was made up about going to the hospital, and also verified not initially notifying the POAHC. The resident was sent to the ER and later died in the hospital.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices With Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices, including appeal rights information, to residents who were transferred to the hospital. For one resident (R2), who had metastasized prostate cancer, a stage 4 pressure ulcer to the right heel, opioid dependence, spinal stenosis of the cervical region, chronic pain, and moderate cognitive impairment, the record showed a hospital transfer on 1/23/26 due to chronic pain and refusal of care. R2 had an activated POA assisting with healthcare decisions. Interviews with the POAs indicated that the Admissions Coordinator informed them that R2 was being kicked out and would not be allowed to return because of complaints of pain, behaviors, refusal of care, uncontrolled pain, and combative behavior. The medical record did not contain any written bed-hold or transfer/discharge notice for R2 or the POAs, and the Admissions Coordinator confirmed that no such notice or discussion occurred. The DON confirmed that no bed-hold or transfer/discharge notice was reviewed or provided because the facility would not accept R2 back and stated unawareness of the requirement to provide such notices, including information on return rights and appeal rights, for all residents transferred to the hospital. For another resident (R13), who had acute on chronic combined systolic and diastolic congestive heart failure, aspiration pneumonia, and intact cognition with responsibility for their own healthcare decisions, the record showed a hospital transfer on 2/1/26. R13’s signed “Bed-Hold for Hospitalization and Therapeutic Leave/Discharge” form was present but lacked required information on appeal rights. Specifically, the form did not include the name, mailing and email address, and telephone number of the entity that receives appeal requests, nor did it provide information on how to obtain an appeal form or receive assistance with completing and submitting an appeal hearing request. The DON stated they were not aware that bed-hold and transfer/discharge notices must include information on appeal rights and verified that the facility’s form did not contain the required appeal information. The DON also indicated that this same form functioned as the facility’s policy and that there was no separate bed-hold or transfer/discharge policy.
Failure to Perform and Document Required Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
Staff failed to provide and document required respiratory assessments in connection with nebulizer treatments for one resident. The facility’s Respiratory policy dated 1/2025 requires qualified nursing staff to assess a resident’s pulse, oxygen saturation, and lung sounds prior to nebulizer administration, and to reassess pulse, oxygen saturation, minutes of nebulizer use, and lung sounds after administration, with all respiratory nursing documentation to include pre- and post-nebulizer treatment assessments. The resident involved had physician orders to self-administer nebulizers and an inhaler after nurse set-up three times daily, and a specific order to assess prior to administering nebulizer treatment and to document lung sounds, pulse, and respirations every six hours for COPD. The Medication Administration Record (MAR) showed that all nebulizer treatments were provided, but the ordered nebulizer assessments were not completed as required. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary edema, and heart failure, and had a BIMS score of 13/15, indicating intact cognition, with an activated POA for healthcare. Despite the resident’s respiratory conditions and the clear policy and physician orders, staff did not assess the resident’s lungs prior to set-up or after the self-administered nebulizer treatments, and these assessments were not consistently documented in the MAR. During interview, the DON confirmed that nebulizer assessments should be documented in the MAR and verified that the resident’s nebulizer assessments were not consistently documented, confirming the failure to follow the facility’s respiratory policy and the physician’s orders for respiratory assessment and documentation.
Failure to Collaborate With Hospice and Fully Utilize Ordered Analgesics for Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management to a hospice resident with metastatic prostate cancer, a stage 4 heel pressure ulcer, osteomyelitis, chronic pain, peripheral neuropathy, cervical radiculopathy, and opioid dependence. The resident had moderate cognitive impairment and an activated healthcare power of attorney. Facility policy required systematic recognition, assessment, treatment, and monitoring of pain, including use of appropriate pain assessment tools, observation of non-verbal indicators, collaboration with the prescriber and hospice, and reassessment and adjustment of medications when pain was not controlled. On the night shift prior to the event, the resident’s pain was documented as 0, but on the following morning shift the pain level was documented as 10 out of 10. On the morning in question, CNAs reported that the resident repeatedly requested pain or gas medication, was rude and demanding, and later was found balled up and non-verbal. Another CNA reported the resident stated they were waiting for pain medication, continued to report severe pain, refused breakfast, and declined non-pharmacological interventions such as an ice pack and repositioning. The DON stated the resident refused assessments on admission and again that morning, while reporting pain at 10 out of 10. The DON also stated that the assigned RN had provided all pain medication the resident could receive and that the pain remained at 10 out of 10, leading to a decision to send the resident to the ER for intractable, uncontrolled pain. However, review of the MAR with the DON showed that additional PRN morphine could have been administered before the transfer time, and the record did not show any documentation that PRN morphine was offered and refused after the 7:01 AM dose. The hospice Director of Clinical Services reported being told by facility staff that the resident had “maxed out” on scheduled and PRN pain medications and was being sent to the ER, but hospice determined the resident had not actually reached the maximum allowable pain medication. Hospice stated they could have assessed the resident and adjusted or increased pain medications, and offered to involve the hospice medical director and send a nurse, but the facility declined and proceeded with the ER transfer. The hospital case manager reported being informed that the resident was being sent back due to pain control and behavior concerns and that hospice had offered solutions which the facility declined. The RN caring for the resident stated the resident complained of pain everywhere at a level 10 out of 10, requested IV pain medication and higher doses of opioids than the facility could provide, and that scheduled and PRN morphine were given close together. The RN documented the PRN morphine as effective despite the resident’s continued aggressive behavior and reported offering additional PRN morphine later, but this offer and any refusal were not documented in the medical record. Hospice later reported that the resident’s hospitalization would not have been necessary had hospice been involved in managing the resident’s pain prior to transfer.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage and preparation practices during an inspection. The kitchen microwave was found to have dried food debris on the interior surfaces, indicating it was not cleaned in accordance with the facility's policy or the Wisconsin Food Code, which requires daily cleaning of microwave cavities and door seals. The Dietary Manager confirmed that the microwave should be cleaned after each use, but it was not cleaned until after the surveyor's observation. In the main kitchen refrigerator, surveyors observed a partially open container of marinara sauce that was past its use-by date and had not been discarded as required. Additionally, a package of celery was found open to air with an open date well beyond the recommended consumption period and without a use-by date. These findings demonstrate that the facility did not consistently follow proper food labeling, storage, and discard procedures as outlined in the Wisconsin Food Code and the facility's own policies. The facility's dishwasher was also found to be deficient. The machine failed to reach the minimum required rinse temperature of 180 degrees Fahrenheit, as indicated on the manufacturer's data plate and required by the Wisconsin Food Code. Despite multiple attempts to run the machine and intervention by the Maintenance Director, the rinse temperature remained below the required threshold, raising concerns about the effectiveness of dish sanitization. These deficiencies had the potential to affect all 35 residents residing in the facility.
Failure to Ensure Healthcare Decisions Made by Properly Delegated Representatives
Penalty
Summary
The facility failed to ensure that the right to make healthcare decisions was exercised only by individuals properly delegated by the resident, in accordance with applicable law, for two residents. In the first case, a resident with moderate dementia and an activated Power of Attorney for Healthcare (POAHC) had a designated agent who resigned. The facility allowed a family member, not listed as a healthcare agent in the POAHC document, to make healthcare decisions and sign medical consents for the resident. Staff interviews confirmed that the family member was not authorized to act as the healthcare agent, and the alternate agent listed in the POAHC was not contacted or involved. In the second case, another resident with moderate cognitive impairment and an activated POAHC was admitted with documentation confirming incapacity and the activation of their healthcare agent. Despite this, the facility had the resident, who was deemed incapacitated, sign multiple healthcare consent forms, including medication consents, a CPR directive, and a vaccine consent. Staff confirmed that the resident's POAHC should have been the one to sign these documents, not the resident themselves. Both incidents demonstrate that the facility did not follow its own policy or state law regarding the delegation of healthcare decision-making authority when a resident is deemed incapacitated. The facility failed to ensure that only the designated healthcare agent, as specified in the POAHC, was making or authorizing healthcare decisions for these residents.
Call Light Inaccessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when a resident's call light was not accessible while the resident was in bed, contrary to the facility's policy requiring call lights to be within reach. The resident, who had Alzheimer's disease, a history of urinary tract infections, moderate cognitive impairment (BIMS score of 9/15), and required assistance with transfers, ambulation, and toileting, was observed multiple times over the course of a morning with the call light lying on the floor approximately five feet from the bed. The resident used a wheelchair and walker and had an activated Power of Attorney for Healthcare. During interviews and observations, the resident indicated an inability to locate or reach the call light when needing to use the bathroom. Staff confirmed the call light was not accessible and acknowledged that it should always be within reach for all residents, as per facility policy. The Director of Nursing also confirmed that the call light should have been accessible at all times.
Failure to Ensure Timely and Accurate PASRR Screening and Documentation
Penalty
Summary
The facility failed to ensure compliance with Pre-admission Screening and Resident Review (PASRR) requirements for three residents with mental illness (MI) diagnoses and/or prescribed psychotropic medications. For these residents, the facility did not update PASRR Level I Screens to reflect changes in prescribed medications and did not submit timely PASRR Level II Screens when the residents remained in the facility beyond 30 days. Additionally, the facility did not obtain required county exemption forms (DHS form F-20822) upon admission for these residents. One resident with major depressive disorder and moderate dementia was admitted with a PASRR Level I Screen indicating MI and psychotropic medication use, but the screen was not updated when medications changed, and a Level II Screen was not submitted in a timely manner. Another resident, admitted with a diagnosis of acute respiratory failure but prescribed psychotropic medications for depression and anxiety, had a PASRR Level I Screen marked for MI and a 30-day hospital exemption, but the Level II Screen was not submitted until after the resident remained in the facility past 30 days. The required county exemption form was also not provided at admission. A third resident with a history of depression and OCD with skin picking was prescribed multiple psychotropic medications, but the PASRR Level I Screen did not reflect all current medications or MI diagnoses. The facility did not update the Level I Screen with new medications, did not submit a Level II Screen, and did not provide the county exemption form. Throughout the survey, the facility was unable to provide complete PASRR documentation or exemption forms for these residents despite multiple requests.
Failure to Provide Timely ADL Assistance and Restorative Care
Penalty
Summary
Two residents did not receive appropriate assistance with activities of daily living (ADLs) to maintain their highest practicable physical well-being. One resident, who had a perirectal abscess with a large residual wound following surgery, experienced delays in receiving timely toileting and incontinence care. This resident reported multiple instances where staff did not respond promptly to call lights, resulting in prolonged periods of sitting in urine or stool. Documentation and interviews revealed that staff sometimes failed to properly clean the resident after incontinence episodes, and on at least one occasion, a staff member declined to provide care, leaving the resident soiled until seen by outside wound clinic staff. The resident expressed discomfort, embarrassment, and concern that inadequate care could affect wound healing. Facility staff, including the Director of Nursing and Social Worker, were not consistently aware of these incidents or the related wound clinic notes. Another resident, with diagnoses including diabetes with polyneuropathy and repeated falls, was discharged from physical therapy with a recommendation for a restorative ambulation program. The program specified ambulation in the hallway once per shift with caregiver assistance. However, the resident's care plan did not include this ambulation or a restorative program, and staff were unaware of the walking schedule. Documentation showed that the resident was not consistently ambulated as recommended, with the majority of opportunities for ambulation marked as 'not applicable,' indicating the task did not occur. The resident expressed a desire to walk in the hallway with staff and reported not walking much since therapy ended. Facility policies required staff to provide timely responses to call lights, maintain residents' ADL abilities, and implement restorative nursing programs as indicated by assessments and therapy recommendations. In both cases, the facility failed to follow its own policies and procedures, resulting in residents not receiving necessary care and services to maintain their physical functioning and dignity.
Failure to Investigate Falls and Update Care Plans After Multiple Incidents
Penalty
Summary
Surveyors identified that the facility failed to ensure areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with a history of falls and cognitive impairment. Three residents with moderate cognitive impairment and significant medical conditions, including dementia, encephalopathy, osteoarthritis, diabetes, and hemiplegia, experienced multiple unwitnessed falls. Despite these incidents, the facility did not conduct thorough fall investigations to identify root causes or update the residents' care plans with new interventions to prevent further falls. The review of medical records revealed that after each fall, the facility did not consistently complete required neurological checks as outlined in their Fall Checklist. For several falls, neuro checks were missing or incomplete, and in some cases, the checks were performed at incorrect intervals. Additionally, the facility lacked a formal falls policy and relied on an undated Fall Checklist, which was not consistently followed by staff. The Director of Nursing confirmed that fall investigations did not identify root causes, care plans were not updated, and neuro checks were not thoroughly completed following unwitnessed falls. For one resident, five falls occurred over a two-week period without any new safety interventions being added to the care plan. Another resident experienced six falls, including incidents resulting in injury and hospital transfer, yet no new interventions were implemented, and one fall was not investigated at all. The facility's failure to follow fall procedures, update care plans, and complete post-fall assessments contributed to the deficiency identified by surveyors.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program based on direct observations, staff interviews, and record reviews involving two residents. One resident with a Foley catheter and multiple diagnoses, including Parkinson's disease and urinary retention, received perineal care from two CNAs who failed to perform hand hygiene between glove changes. The CNAs changed gloves multiple times during care, touched various clean and contaminated surfaces, and only performed hand hygiene after leaving the resident's room, contrary to facility policy. Another resident with a PEG tube and Parkinson's disease received pericare from an LPN who did not wash hands before donning gloves and did not wear a gown, despite the resident's use of an indwelling medical device. There was also no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the resident's room, as required by facility policy. The LPN stated a misunderstanding of when gown use was necessary, believing it was only required if the resident was sick. Facility policies reviewed by surveyors clearly outlined the need for hand hygiene before and after glove use, the use of gowns and gloves during high-contact care activities for residents with indwelling devices, and the posting of EBP signage and availability of PPE. Both direct care staff and the Director of Nursing confirmed during interviews that the observed practices did not align with facility policies and procedures.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was completed as ordered for two residents, leading to a finding of immediate jeopardy. Resident 1, admitted for rehabilitation following surgery for Charcot's foot, had a physician's order for daily dressing changes. However, these dressing changes were not completed from May 22 to May 27, resulting in the discovery of maggots in the surgical wound by a registered nurse. The resident was subsequently transferred to the hospital for wound debridement and treatment with intravenous antibiotics. Resident 4 also experienced a lapse in wound care. The resident had a treatment order for a chronic ulcer on the right heel and midfoot, which required dressing changes three times a week. On June 14, the dressing change was not completed as ordered, and there was no documentation to indicate the treatment was performed. The Director of Nursing confirmed the missed treatment, and a subsequent dressing change revealed the previous dressing had not been changed since June 12. The facility's failure to adhere to the prescribed wound care regimen for these residents resulted in significant harm for Resident 1 and potential harm for Resident 4. The lack of documentation and follow-through on ordered treatments contributed to the deficiencies identified by the surveyors.
Removal Plan
- Initiated staff-wide education regarding wound care, neglect, TAR/Medication Administration Record (MAR) sign-outs, and resources.
- Initiated ongoing review with staff during huddles.
- Reviewed all current residents with wounds to ensure dressings were changed as ordered.
- Initiated a plan to complete dressing change audits to ensure all dressings are changed as ordered.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a sanitary manner, potentially affecting all 24 residents. During an initial kitchen tour, it was observed that the kitchen cooler contained items such as beef tips, cream of soup, and turkey soup that were not listed on the cooling log. The Dietary Manager confirmed that the facility's process is to document food cooling temperatures on the cooling log to ensure food is cooled safely with an approved cooling method. However, the leftover items in the cooler were stored without following the facility's cooling policy, which is a violation of the Wisconsin Food Code 2022 regarding cooling methods and time/temperature control for safety food. Additionally, the cleanliness of the kitchenettes was found to be inadequate. During a tour of the [NAME] Garden Home kitchenette, it was noted that the toaster contained crumbs, the refrigerator had multiple brown and white smudged food particles on the outside doors and handles, and the inside door of the vegetable crisper contained brown food particles, dried lettuce leaves, and onion skins. The bottom of the refrigerator and the bottom drawer of the freezer also contained various stains, discarded twist ties, and food particles. These unsanitary conditions were observed on two separate days, and the Dietary Manager confirmed that the kitchenettes should be cleaned daily and as needed by staff, which was not being done.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility did not ensure the resident environment for one resident was as free of accident hazards as possible. The facility failed to implement fall interventions contained in the resident's person-centered comprehensive care plan and medical record. The resident, who had severe cognitive impairment and multiple diagnoses including chronic diastolic heart failure and type 2 diabetes, experienced several falls resulting in injuries. Despite the care plan specifying interventions such as keeping the bed in the lowest position and placing a floor mat next to the bed, these measures were not consistently followed. Observations by the surveyor revealed the bed was not in the lowest position and the floor mat was not in place on multiple occasions. The resident's medical record indicated a history of falls, including incidents where the resident slid out of a wheelchair, fell from a recliner, and fell from bed, resulting in injuries such as a fractured left arm and femur. The Director of Nursing confirmed the interventions were required and acknowledged the failure to implement them. The lack of adherence to the care plan interventions contributed to the resident's repeated falls and injuries, highlighting a significant deficiency in ensuring a safe environment for the resident.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Oshkosh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Health Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Bethel Home | 2.2 mi | ★★★★★ | 11 | 1 |
| Edenbrook Of Oshkosh | 4.6 mi | ★★★★★ | 3 | 0 |
| Park View Health Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Edenbrook Omro | 6.8 mi | ★★★★★ | 35 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.