Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Edenbrook Of Fond Du Lac during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
A resident with a legal guardian and multiple psychiatric diagnoses was prescribed lorazepam, but the facility did not obtain informed consent from the guardian at the time the medication was ordered. Staff interviews and record review confirmed that the required consent process was not followed, and documentation was only completed after the issue was identified by a surveyor.
A resident with multiple chronic conditions was found with an albuterol inhaler and artificial eye gel drops at the bedside without the necessary physician orders or completed self-administration assessment. Staff and the DON confirmed that facility policy requires orders and assessment for medications to be kept at the bedside, which were not present in this case.
A registered nurse did not wear required PPE, including gown and gloves, while providing high-contact care to a resident on Enhanced Barrier Precautions due to MDRO colonization. The nurse's uniform contacted the resident's bed linens during medication administration and pillow adjustment, contrary to facility policy. Both the RN and DON confirmed that PPE should have been used during these activities.
A resident with a Foley catheter and complex medical history received a bladder flush with vinegar instead of the prescribed acetic acid solution, resulting in severe discomfort and subsequent gross hematuria. The LPN who administered the flush did not report the medication error or notify the physician, and the facility failed to promptly inform medical providers about the resident's ongoing bleeding, delaying appropriate medical intervention.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a multidrug-resistant organism (MDRO). Two CNAs provided peri-care and a mechanical lift transfer without wearing gowns, despite the presence of an EBP sign and PPE cart. One CNA was unfamiliar with EBP, and the other misidentified the PPE cart's purpose. The Director of Nursing confirmed the need for gowns and gloves during high-contact care, as indicated in the resident's care plan and medication record.
A CNA in an LTC facility failed to adhere to infection control protocols while caring for a resident on Enhanced Barrier Precautions. The CNA used soiled gloves to handle personal items, did not change gloves between tasks, and neglected hand hygiene. The resident had multiple infections and was on precautions for carbapenem-resistant Acinetobacter baumannii. The facility's policies on infection control and hand hygiene were not followed, as confirmed by the DON.
The facility failed to ensure safe and sanitary food storage and preparation, affecting all 47 residents. A staff member did not wash hands after handling soiled dishes before touching clean ones, violating FDA guidelines and facility procedures. Additionally, the facility did not maintain cooling logs for leftovers, breaching FDA guidelines and facility policy.
The facility failed to monitor potential adverse reactions to high-risk medications for four residents. Staff did not monitor for side effects of antibiotics and anticonvulsants, despite facility policy and CDC guidelines. Residents with chronic osteomyelitis, a trimalleolar fracture, bollous pemphigoid, and neuropathy were affected, with care plans lacking necessary monitoring interventions.
An LPN at the facility failed to follow hand hygiene protocols during medication administration and resident assistance, as observed in multiple instances. The LPN did not perform hand hygiene before or after administering medication to residents, including those on contact precautions, and handled items that had fallen on the floor without sanitizing hands. The facility's policies on hand hygiene were not followed, as confirmed by the LPN and the Director of Nursing.
The facility failed to implement its policies to prevent abuse, neglect, and theft by hiring a cook without completing a thorough background check. The cook had a pending charge for a qualifying offense, and the facility did not obtain necessary information before employment. The Nursing Home Administrator and Human Resource Director were aware of the charges but did not follow up until after a conviction for disorderly conduct was revealed.
A resident with schizoaffective disorder and other mental health diagnoses was admitted to the facility and prescribed psychotropic medications. Despite a positive PASRR Level I Screen indicating mental illness, the facility did not complete a PASRR Level II Screen following changes in the resident's condition and medication. Interviews with staff confirmed the necessity of a Level II Screen, but the facility lacked a PASRR policy, leading to this oversight.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Obtain Timely Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's legal guardian was informed of the risks and benefits of a prescribed psychotropic medication, lorazepam, as required by facility policy and state regulations. The resident, who had intact cognition and diagnoses including schizophrenia, generalized anxiety disorder, major depressive disorder, and mood affective disorder, had a legal guardian appointed. Lorazepam was ordered for the resident, but there was no documentation of informed consent from the guardian at the time the medication was prescribed. Staff interviews and record reviews revealed that the facility's process for obtaining informed consent was not followed. The Director of Nursing stated that informed consent is usually obtained when psychotropic medications are ordered, and that medications are not administered without signed consent. However, the social worker confirmed that consent was not obtained until after the surveyor's request, and there was no documentation of verbal consent or attempts to contact the guardian prior to the survey. The resident had not received lorazepam before the consent was obtained, but the required documentation and process were not completed in a timely manner.
Failure to Ensure Safe Medication Administration and Storage at Bedside
Penalty
Summary
A deficiency occurred when a resident was found with an albuterol inhaler and artificial eye gel drops at their bedside without the required physician orders or proper assessment documentation. The facility's policies require that medications be administered according to provider orders and that residents must be assessed and have a physician order to self-administer or keep medications at the bedside. The resident, who had diagnoses including heart failure, COPD, type 2 diabetes, and pneumonitis, was alert, oriented, and able to make their own medical decisions. However, the only self-administration assessment on file pertained to nebulizer use, and there were no orders for the resident to self-administer the inhaler or eye drops, nor to store these medications at the bedside. Surveyors observed the medications at the bedside and confirmed with both the resident and staff that the resident used the inhaler for shortness of breath and the spouse administered the eye drops. Nursing staff and the Director of Nursing acknowledged that the medications should not have been at the bedside without appropriate orders and assessment. The lack of proper documentation and orders for self-administration and bedside storage of these medications constituted a failure to provide pharmaceutical services in accordance with facility policy and regulatory requirements.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing care to a resident who was colonized with a multidrug-resistant organism (MDRO). The resident, who had a history of atrial fibrillation, mild cognitive impairment, and urinary tract infection, was under EBP to prevent the spread of the MDRO. The facility's policy required staff to don gown and gloves during high-contact care activities, such as changing linens or any care that could transfer MDROs to staff hands or clothing. During observation, the RN administered oral medications and eye drops to the resident without wearing a gown or gloves. While administering the eye drops and adjusting the resident's pillow and pillowcase, the RN's uniform top came into contact with the resident's bed linens, which constituted high-contact care. The RN later acknowledged that PPE should have been worn during these activities, and the Director of Nursing confirmed this requirement according to facility policy.
Failure to Provide Appropriate Catheter Care and Timely Physician Notification
Penalty
Summary
A resident with a history of kidney stones, neuromuscular bladder dysfunction, chronic heart failure, and atrial fibrillation, who was on anticoagulant medication and had a Foley catheter, experienced inappropriate catheter care. The resident had physician orders for bladder irrigation using 0.25% acetic acid solution, but a nurse was unable to locate the prescribed solution and instead used vinegar, believing it to be equivalent. The vinegar was instilled into the resident's bladder, causing a severe burning sensation. The nurse did not clamp the catheter as ordered due to the resident's complaint but failed to document the incident or notify the physician or family about the medication error. Following the vinegar flush, the resident experienced gross hematuria (significant blood in the urine) for several days. Despite ongoing bleeding, the facility did not promptly notify the resident's physician, nurse practitioner, or urologist. Documentation shows that the nurse practitioner and urologist were only updated after several days of continued hematuria, and the urologist ultimately recommended the resident be transferred to the emergency room for evaluation. The delay in notification was contrary to the facility's policy, which required prompt reporting of significant changes in condition, such as marked differences in usual signs or symptoms, including gross hematuria. Interviews with facility staff revealed that the Director of Nursing was initially unaware of the incident and only learned about the use of vinegar from the resident's family days later. The nurse involved admitted to using vinegar due to confusion about the solutions and acknowledged not reporting the error. The facility's investigation confirmed that the incident was not reported in a timely manner, and there was a lack of staff education regarding the importance of immediate physician notification when blood is observed in a resident's urine.
Failure to Implement Enhanced Barrier Precautions for Resident with MDRO
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper implementation of Enhanced Barrier Precautions (EBP) for a resident with a multidrug-resistant organism (MDRO). On the specified date, two Certified Nursing Assistants (CNAs) were observed providing peri-care and a mechanical lift transfer for a resident diagnosed with vascular dementia and colonized with Klebsiella pneumoniae in the urine, which is resistant to a broad range of antibiotics. Despite the presence of an EBP sign and a personal protective equipment (PPE) cart near the resident's door, the CNAs only donned gloves and not gowns, as required by the facility's EBP policy during high-contact resident care activities. The CNAs' lack of adherence to the EBP protocol was further highlighted when one CNA was unfamiliar with EBP, and the other mistakenly believed the PPE cart was for a different resident. The Director of Nursing confirmed that staff should wear a gown and gloves, and possibly a face shield or mask, during high-contact care for residents on EBP. The resident's care plan and medication administration record indicated the need for EBP due to the presence of MDROs, yet the staff failed to follow these precautions, leading to a deficiency in the facility's infection control practices.
Infection Control Deficiency Due to Improper PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during the care of a resident on Enhanced Barrier Precautions (EBP). The CNA, identified as CNA-D, was observed reaching inside their gown with soiled gloves to retrieve a walkie talkie, touching the front of their uniform with soiled gloves, and failing to change gloves between dirty and clean tasks. Additionally, the CNA threw soiled linens on the resident's floor and did not perform hand hygiene after removing their gown and gloves before leaving the room. The resident involved, identified as R6, had multiple diagnoses including sepsis, cellulitis, type 2 diabetes, MRSA, ESBL, and pressure ulcers, and was on EBP for carbapenem-resistant Acinetobacter baumannii. The facility's policies on infection control, EBP, and hand hygiene were not followed, as confirmed by interviews with the CNA and the Director of Nursing (DON). The DON acknowledged that the staff should adhere to the facility's EBP policy and contact precautions, and confirmed the improper handling of soiled linens and the lack of appropriate hand hygiene by the CNA.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure food was stored and prepared in a safe and sanitary manner, potentially affecting all 47 residents. During a kitchen tour, it was observed that a staff member, CK-D, did not perform hand hygiene after handling soiled dishes and before handling clean dishes, which is a violation of the 2022 FDA Food Code and the facility's own dishwashing procedures. Despite removing gloves after handling dirty dishes, CK-D did not wash hands before touching clean dishes, which was against the expected practice as stated by both CK-D and other dietary staff. The Dietary Manager (DM-C) confirmed that the facility's procedure requires two staff members to handle dishes to prevent cross-contamination, with one handling dirty dishes and another handling clean ones. Additionally, the facility did not maintain cooling logs for leftover food, which is a requirement under the 2022 FDA Food Code. The surveyor observed leftover soup in the walk-in refrigerator, and the Dietary Manager admitted that while leftovers are not routinely kept, certain items are occasionally stored without checking their temperatures before refrigeration. The facility's policy requires cooked time/temperature control for safety (TCS) foods to be cooled and logged appropriately, but the dietary staff did not maintain a cooling temperature log, which is a breach of the facility's policy and the FDA guidelines.
Failure to Monitor Adverse Reactions to Medications
Penalty
Summary
The facility failed to ensure that potential adverse reactions to high-risk medications were monitored for four residents. Specifically, the staff did not monitor three residents for potential side effects or adverse reactions to antibiotic medications, and three residents for potential side effects or adverse reactions to anticonvulsant medications. The facility's policy required monitoring for complications related to antiepileptic medications, and the CDC guidelines highlighted common side effects of antibiotics. However, the facility did not adhere to these guidelines, resulting in a lack of monitoring for adverse reactions. Resident 22, with a diagnosis of chronic osteomyelitis, was prescribed gabapentin and antibiotics but was not monitored for adverse side effects. Similarly, Resident 46, with a trimalleolar fracture, was prescribed Lyrica and an antibiotic without monitoring for adverse reactions. Resident 11, prescribed minocycline for bollous pemphigoid, and Resident 30, with diabetes and neuropathy, prescribed gabapentin, also lacked monitoring for potential adverse reactions. Interviews with the Director of Nursing and Nursing Home Administrator confirmed the absence of monitoring interventions in the care plans for these residents.
Failure to Adhere to Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during medication administration and resident assistance, as observed in the actions of an LPN. The LPN did not perform hand hygiene before or after administering medication to several residents, including those on contact and enhanced barrier precautions. Specific instances included preparing and administering medication without washing hands, handling items that had fallen on the floor, and touching various surfaces without sanitizing hands in between tasks. The facility's policies on administering medications and hand hygiene were not adhered to, as evidenced by the LPN's actions. The LPN acknowledged missing several opportunities for hand hygiene and confirmed that the alcohol pad used after falling on the floor should have been discarded. The Director of Nursing also confirmed that hand hygiene should be performed between residents and after medication disposal, highlighting the lapses in following established infection control procedures.
Failure to Implement Background Check Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit mistreatment, neglect, and abuse of residents, as evidenced by the hiring of a cook (CK-F) without completing a thorough caregiver background check. CK-F was hired on February 20, 2024, and had a Department of Justice document indicating a charge for a qualifying offense on June 27, 2024. The facility did not obtain additional information from the Clerk of Courts regarding the disposition of the case or the facts of the incident. The Wisconsin Background Check and Misconduct Investigation Program Manual requires a complete caregiver background check, which includes a Background Information Disclosure form, a response from the DOJ, and a Governmental Findings Report. However, the facility did not obtain the necessary criminal complaint or judgment of conviction from CK-F before employment. During the survey, it was revealed that CK-F had been convicted of disorderly conduct on April 19, 2024, which was not disclosed to the facility as per its policy. The Nursing Home Administrator (NHA-A) and Human Resource Director (HRD-G) were aware of the charges but did not follow up on the pending charges or obtain additional information until after the conviction. HRD-G acknowledged not following up with CK-F and stated that a process would be implemented to ensure follow-up is completed. This oversight in the background check process led to a deficiency in the facility's compliance with its policies to prevent abuse, neglect, and theft.
Failure to Complete PASRR Level II Screen for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure compliance with the Pre-Admission Screening and Resident Review (PASRR) requirements for one resident, identified as R30. R30, who was admitted to the facility with diagnoses including schizoaffective disorder, major depressive disorder, and anxiety, had a positive updated PASRR Level I Screen indicating the presence of mental illness. Despite being prescribed psychotropic medications such as Clozaril and Paxil, a PASRR Level II Screen was not completed following a change in R30's condition, which included recent auditory/visual hallucinations and medication adjustments. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that a PASRR Level II Screen should have been initiated due to the changes in R30's mental illness condition and medication regimen. The Behavioral Consulting Services Staff also clarified that a Level II Screen is necessary when there is a change in medication or if mental illness symptoms are not controlled. The facility lacked a PASRR policy, which contributed to the oversight in not completing the required Level II Screen for R30.
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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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fond Du Lac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Haven Health & Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| Avina On Division | 0.6 mi | ★★★★★ | 11 | 1 |
| St Francis Home | 0.8 mi | ★★★★★ | 12 | 0 |
| Avina Of Fond Du Lac | 1.5 mi | ★★★★★ | 6 | 0 |
| Fond Du Lac Lutheran Home | 1.7 mi | ★★★★★ | 24 | 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.