Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Green Bay during CMS and state inspections, most recent first.
Missing post-fall assessments and admission nursing documentation: The facility did not complete required post-fall assessments for one resident who had multiple falls and significant medical history including psychotropic use, epilepsy, and diabetes. A second resident was admitted with multiple serious diagnoses, but the initial nursing documentation lacked key assessments, vital signs, skin findings, medication details, and ADL assistance needs; later charting noted a left lower extremity wound vac, pain, and bedbound status. Staff and the DON confirmed the expected alert/daily skilled charting and admission documentation were not completed.
Missing Monitoring Documentation for Residents on Antibiotic Therapy: The facility did not ensure required alert charting and monitoring for adverse reactions for three residents receiving antibiotic therapy, including a resident on oral vancomycin for C. diff, a resident on IV cephalexin for cellulitis after sepsis, and a resident on IV ceftriaxone for osteomyelitis and sepsis. The DON verified the records lacked the required documentation, and an RN stated alert charting was not completed as required.
A resident with critical hypokalemia did not receive a timely potassium re-check after an NP ordered the lab to be drawn by 3:00 PM. The TAR showed the order was not completed, and staff interviews confirmed the RN transcribed the order, the LPN did not obtain the draw that day, and the lab was not completed until the next day.
Unqualified Dietary Manager: The facility did not designate a qualified director of food and nutrition services. The dietary manager had not passed the certification test, was not certified, did not have a food service manager certification or a relevant degree, and no waiver had been filed with the SA. The RD was aware of the issue and was working with the dietary manager to study for the next test.
A facility failed to maintain infection prevention and control practices for three residents. For one resident with recurrent C. diff, staff did not consistently use gown and glove PPE, did not complete hand hygiene as required, and handled soiled linens improperly; the resident’s Kardex also did not reflect contact precautions. For another resident with a Foley catheter and nephrostomy tube, an LPN and CNA performed high-contact care without gowns despite EBP being indicated. For a third resident with open wounds, EBP was not started promptly and staff provided high-contact care without the required PPE.
Dignity Not Maintained During Mealtime Assistance: A CNA moved between three residents who needed feeding help and stood while feeding them in the dining room. The residents had significant cognitive and physical impairments, including dementia, Parkinson’s disease, muscular dystrophy, and severe cognitive impairment. Staff later stated that aides should sit down while feeding residents, and one CNA said the observed practice was typical.
Failure to Notify Provider of Significant Weight Gains Three residents with CHF had significant weight gains that met physician order thresholds for provider notification, but the medical records did not show the provider was updated. One resident had multiple large gains, including a 33-pound increase, another had repeated gains over 3 to 5 pounds, and a third had a 9.3-pound gain. Staff interviews confirmed the gains should have been communicated to the provider, but documentation of notification was absent.
A resident on hospice care with multiple serious diagnoses experienced a significant delay in receiving PRN morphine for pain, waiting approximately two hours after requesting the medication. Staff interviews and record review confirmed the delay was due to ineffective communication and failure to follow the facility's pain management policy, resulting in the resident's pain needs not being met promptly.
Surveyors found that an LPN administered medications to two residents without dating the medications upon opening, and left a medication cart unlocked and unattended with a resident's MAR visible during medication administration. Both the LPN and DON confirmed these actions did not follow facility policy.
A resident with type 2 diabetes was given the wrong insulin when an LPN administered Basaglar instead of the prescribed insulin aspart before a meal. The error was discovered when the LPN could not locate the correct insulin in the medication cart and the MAR inaccurately reflected the administration. The facility's medication administration policy requiring verification of the correct medication was not followed.
Staff did not adhere to infection control protocols, as an LPN failed to perform hand hygiene before and after medication administration for multiple residents, and a CNA used wash cloths prepared in an unsanitized sink for pericare. The facility's policy did not clearly specify procedures for pericare, contributing to inconsistent practices.
A resident with multiple health conditions activated their call light to request coffee, but the request was unmet for over an hour due to a change in procedure. The CNA turned off the call light without providing coffee, as dietary staff had instructed CNAs not to provide coffee directly. The dietary manager confirmed the new procedure required CNAs to request coffee via radio, which was not communicated to the resident. The DON stated call lights should remain on until needs are met.
The facility failed to consistently obtain daily weights for two residents with CHF and other conditions, as required by their care plans. Both residents had numerous missing weight records due to insufficient staffing to perform necessary transfers before breakfast. Staff interviews confirmed the lack of staffing as a reason for the missed weights, and the issue was acknowledged by the NP and DON.
The facility failed to follow care plans for two residents requiring mechanical lift transfers, resulting in unsafe practices due to inadequate staffing. Both residents, with specific medical conditions, were supposed to be assisted by two staff members during transfers, but often only one staff member was available. Staff interviews confirmed this ongoing issue, and the DON acknowledged the requirement for two staff members was not consistently met.
The facility failed to maintain accurate daily nursing staff postings, listing full shift hours even when staff worked partial shifts, and did not retain these postings for 18 months. Discrepancies were found between the postings and actual schedules, with the Nursing Home Administrator and Staffing Coordinator confirming the lack of updates for schedule changes.
The facility failed to maintain CPAP and BiPAP machines for four residents, neglecting to replace filters as per manufacturer guidelines. Residents with conditions like COPD and sleep apnea had machines with dirty or missing filters, compromising their respiratory care. The DON confirmed the lack of maintenance and supplies for filter replacement.
The facility did not adhere to prescribed diet serving sizes for residents requiring therapeutic and mechanically altered diets. A resident on hemodialysis was not served the correct double protein portion, and others with conditions like dysphagia and cerebral palsy received smaller portions than required. The Dietary Manager confirmed that meal tickets and care plans were not updated, leading to incorrect servings.
A resident was observed with medication at their bedside without a self-administration assessment or physician's order. The resident, who had intact cognition, confirmed self-administering the medication. Facility policy requires a nurse's assessment and a physician's order for self-administration, and medications should be secured. The DON confirmed the lack of required documentation and ordered the medication's removal.
A resident with intact cognition and a history of giving cigarettes to others was observed with smoking materials in their wheelchair, contrary to the facility's policy requiring such items to be stored at the nurses' station. Despite being assessed as needing the facility to store their smoking materials, the resident was allowed to keep these items, highlighting a failure to enforce the smoking policy and ensure a safe environment.
The facility failed to prevent urinary tract infections for two residents with indwelling catheters by not adhering to its catheter care policies. Observations showed that the catheter drainage bags were uncovered and in contact with the floor, contrary to the facility's guidelines. Despite the Director of Nursing's expectations for staff to cover the bags and maintain proper hygiene, a CNA was observed not addressing the improper positioning of a catheter bag.
The facility failed to properly label and store medications for three residents, leading to discrepancies in medication management. A nurse administered insulin with a dosage discrepancy, and another resident received eye drops without an open date. Additionally, wound care solutions were improperly stored at a resident's bedside, contrary to facility policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with wounds and another with an indwelling catheter. Despite the facility's policy requiring EBP for such conditions, there were no EBP signs on the residents' doors, leading to staff not wearing necessary PPE during care. The Director of Nursing confirmed the oversight, highlighting a lapse in infection control measures.
A resident at the facility consented to receive the PCV20 vaccine, but it was not administered due to a staff oversight. The resident, who had intact cognition, signed a consent form, but the vaccine was not given. The ADON acknowledged the mistake, stating the form was likely filled out incorrectly, and confirmed that the vaccine should have been administered per facility policy and CDC guidelines.
Missing post-fall assessments and admission nursing documentation
Penalty
Summary
The facility did not ensure assessments and daily skilled/alert charting were completed for 2 residents. One resident, with diagnoses including schizoaffective disorder, bipolar type, Takotsubo syndrome, epilepsy, and type II diabetes, was identified as a moderate fall risk due to impaired balance, amputation, and psychotropic medication use. The resident fell multiple times, including on 4/28/26, 5/12/26, 5/13/26, and 5/19/26, but the medical record did not contain post-fall assessments on 5/14/26 and 5/19/26 to show the resident was monitored and evaluated after the falls. A second resident was admitted with diagnoses including type II diabetes, CKD, sepsis, hypertension, and major depressive disorder, but the admission progress note did not include initial nursing assessments, a skin assessment, vital signs, prescribed antibiotic information, other high-risk medications, or documentation of assistance needed with ADLs. The resident was later documented as having osteomyelitis of the left lower extremity, a wound vac on a left lower ankle wound, pain treated with oxycodone, and remaining in bed for meals. Staff interviews confirmed alert charting was expected for falls and daily skilled charting for monitoring antibiotics, skin conditions, and infections, and the DON verified the resident’s admission documentation was not in accordance with facility practice.
Missing Monitoring Documentation for Residents on Antibiotic Therapy
Penalty
Summary
The facility did not ensure monitoring of high-risk medications for 3 of 4 sampled residents who were prescribed antibiotics. R7 was receiving oral vancomycin for C. diff infection, R11 was receiving IV cephalexin for cellulitis after hospitalization for sepsis secondary to UTI and bilateral lower extremity cellulitis, and R12 was receiving IV ceftriaxone sodium for osteomyelitis and sepsis. Their medical records did not show documentation that staff monitored them for adverse reactions to the antibiotic therapy on the dates identified in the report. The facility’s Policy and Procedure Alert Charting, revised 11/13/24, states that follow-up documentation is required for residents on antibiotic/anti-infective therapy for the duration of therapy. The DON stated alert charting is required each shift to ensure monitoring for adverse reactions when a resident is prescribed antibiotics, and the DON and ADON verified that R7, R11, and R12’s records lacked the required monitoring documentation. RN-G stated staff monitor and complete alert charting for residents on antibiotics, but RN-G did not complete alert charting and instead documented an assessment in a daily skilled nursing progress note. The facility did not provide the requested policy on high-risk medication monitoring.
Delayed Potassium Lab Draw
Penalty
Summary
The facility did not provide timely laboratory services for one sampled resident when a potassium re-check ordered for critical hypokalemia was not completed by the ordered time. The resident had diagnoses including paraplegia, pneumonia, diabetes, cirrhosis of the liver, and anxiety, and had intact cognition with a BIMS score of 15 out of 15. A lab result showed the resident’s potassium level was 2.7 mmol/L, and Nurse Practitioner E ordered oral potassium and a repeat potassium draw by 3:00 PM the same day. The resident’s TAR reflected the order for the potassium re-check, but it was not initialed as completed. During interviews, NP-E stated the re-check was not completed and said it was unacceptable, noting the order was given because of a critically low potassium level. RN-C stated the verbal order was received, oral potassium was given, and the lab order was transcribed, but the lab was not drawn as ordered. LPN-D stated the order did not specify a time and that by the time medication pass was completed it was after 6:00 PM, so the lab was not drawn. DON-B verified the potassium lab was drawn the next day instead of as ordered and was unsure why it was not completed on the ordered date.
Unqualified Dietary Manager
Penalty
Summary
The facility did not designate a person to serve as the director of food and nutrition services who met the required qualifications of being a certified dietary manager, a certified food service manager, holding a national certification for food service management and safety from a national certifying body, or having an associate's or higher degree in food service management or hospitality. This deficiency was identified through staff interview and record review and was noted as having the potential to affect all 70 residents in the facility. During review of the dietary manager's credentials, the surveyor received documentation showing the dietary manager did not pass the dietary manager certification test and was not certified. The nursing home administrator stated the dietary manager had not passed the test, could not retake it for 90 days, and that no waiver had been filed with the State Agency for the position. The dietary manager confirmed failing the test and stated there was no food service manager certification or relevant degree. The registered dietitian was aware of the lack of required certification and stated they were working with the dietary manager to study for the next test.
Infection control precautions not followed for residents on contact precautions and EBP
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for three residents. For one resident with recurrent Clostridium difficile (C. diff), surveyors observed contact precautions were not consistently followed. The resident had diagnoses including quadriplegia, neuromuscular dysfunction of bladder, neurogenic bowel, and ESBL, a BIMS score of 6, and an activated POAHC. Although the resident had positive C. diff testing, was receiving oral vancomycin, and later had C. diff added to the diagnosis list, the resident’s Kardex did not indicate contact precautions and the medical record initially did not contain C. diff as a diagnosis. During observations of care for this resident, staff did not don the appropriate PPE and did not complete hand hygiene as required before entering and exiting the room. A CNA changed bed linens without a gown or gloves, held the linens and gown against the body, exited without hand hygiene, and placed the soiled linens in a hallway cart before using a computer keyboard. A housekeeper cleaned the bathroom wearing gloves but no gown, then removed gloves in the hallway and used hand sanitizer. Staff interviews confirmed confusion about the required PPE and linen handling for C. diff, and the infection preventionist and assistant director of nursing stated staff entering the room should wear gown and gloves and perform hand hygiene before exiting. For a second resident with a Foley catheter, right nephrostomy tube, CKD stage 4, UTI, ESBL resistance, and acute cystitis with hematuria, enhanced barrier precautions were not followed during high-contact care. The resident’s care plan and Kardex indicated EBP, and surveyors observed an EBP sign on the door. However, an LPN changing the nephrostomy dressing and a CNA assisting with turning wore gloves but no gowns. Both staff later acknowledged they should have worn gowns for the care provided. For a third resident with severe dementia and open wounds, EBP was not initiated in a timely manner and was not followed during high-contact care. Surveyors initially found no EBP sign or PPE cart near the room, and the ADON later posted an EBP sign but was unsure why it was needed. The ADON thought the sign was for ESBL, and staff were unsure whether the resident had wounds or why the resident had been taken off EBP. Later, two CNAs entered the room and performed a Hoyer lift transfer without gowns or gloves, stating they were not aware the resident was on EBP. The infection preventionist stated an EBP sign should have been posted before the observation and that the resident’s open wound should have triggered EBP right away.
Dignity Not Maintained During Mealtime Assistance
Penalty
Summary
The facility did not maintain dignity during mealtime for 3 of 4 sampled residents who required assistance with eating: R22, R29, and R59. On 8/26/25, a surveyor observed CNA-J moving between the three residents at different tables in the second-floor main dining room while providing breakfast assistance. CNA-J stood while feeding each resident, gave R59 one spoonful of food and then walked away to assist R29, applied a clothing protector to R29 and fed R29 while standing, then walked to R22 and fed R22 while standing before returning to R29 and continuing to feed R29. CNA-J later retrieved a chair and sat down to feed R29, but then stood again to continue feeding R29 until finished. CNA-J also returned to R22, fed a few bites while standing, walked away, and later returned to finish feeding R22 while standing. R22's record showed diagnoses including Parkinson's disease, dementia, cancer, end stage renal disease, diabetes, and hemiplegia/hemiparesis, and an MDS dated 6/23/25 indicated R22 was rarely or never understood. R29's record showed diagnoses including muscular dystrophy, calorie deficit at risk for malnutrition, and Friedreich's ataxia, and an MDS dated 8/11/25 showed a BIMS score of 6 out of 15, indicating severely impaired cognition. R59's record showed diagnoses including severe dementia with psychotic disturbance, schizoaffective disorder, panic disorder, and anxiety, and an MDS dated 8/25/25 showed a BIMS score of 3 out of 15, indicating severely impaired cognition. CNA-P stated the observed dining room care was a typical occurrence, and the NHA, DON, and RD each stated staff should sit down while feeding residents.
Failure to Notify Provider of Significant Weight Gains
Penalty
Summary
The facility did not provide the necessary care and services to maintain the highest practicable physical well-being for three residents with CHF because provider notification was not documented when significant weight gains occurred. The facility’s Heart Failure policy required nurses to call the provider for a weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week, and to update the provider with changes in condition. R65 had diagnoses including chronic systolic CHF, diabetes, and an acquired absence of the left leg below the knee, and had intact cognition. R52 had CHF and diabetes with intact cognition. R9 had CHF, hypertension, chronic kidney disease, diabetes, and moderate cognitive impairment. For R65, the record showed multiple weight increases that met the facility’s and physician’s notification thresholds, including gains of 6.4 pounds, 6.6 pounds, 4.2 pounds, 8.3 pounds, 5.1 pounds, 4.6 pounds, 7.4 pounds, 33 pounds, 5.6 pounds, and 9.8 pounds on various dates. The physician’s orders required daily weights and provider notification for gains of 3 pounds in 24 hours or 5 pounds in one week, but the medical record did not indicate the provider was updated for these weight changes. RN-M confirmed the weight changes met the order and should have been communicated, and IP-D confirmed the record did not show provider notification and stated the 33-pound gain should have triggered a re-weigh and progress note. For R52, the record showed weight gains of 4.2 pounds, 7.3 pounds, and 4.6 pounds over short intervals, and the physician’s orders required daily weights and provider notification for gains of 3 pounds in 24 hours or 5 pounds in one week. The medical record did not indicate the provider was notified when these significant gains occurred. For R9, the care plan addressed CHF and weight gain, and the physician ordered weights on Monday, Wednesday, and Friday with provider notification for gains of 3 pounds in 24 hours or 5 pounds in one week. R9 had a documented 9.3-pound gain, but the record did not show the provider was notified. DON-B could not verify that the provider was updated within 24 to 48 hours of identifying the significant weight gain.
Delay in PRN Pain Medication Administration for Hospice Resident
Penalty
Summary
A deficiency occurred when a resident receiving hospice services, with diagnoses including lung cancer, brain cancer, COPD, and generalized anxiety disorder, did not receive prescribed PRN morphine for pain in a timely manner. The resident, who was cognitively intact, reported waiting approximately two hours for pain medication after requesting it. Staff interviews confirmed that there was a delay in administering the medication, as communication between nurses and CNAs was not effective, leading to the resident's request being overlooked until a CNA followed up. Documentation showed the resident had ongoing pain and discomfort, including issues with constipation, but the pain medication was not provided promptly as ordered. The facility's pain management policy required timely assessment and administration of pain medication, but this was not followed in the incident. The Assistant Director of Nursing was not initially aware of the delay, and the nurse responsible did not report the incident as required. The event was later identified through interviews and record review, confirming that the resident's pain management needs were not met according to policy and physician orders.
Failure to Properly Label and Secure Medications and MARs
Penalty
Summary
Surveyors observed that staff failed to properly label and store medications for two residents during medication administration. Specifically, an LPN administered timolol maleate ophthalmic solution to one resident and Basaglar KwikPen insulin to another without either medication being dated upon opening, as required by facility policy. The eye drops had been opened and dispensed over two months prior, and the insulin pen had also been dispensed several days before the observation, but neither contained an open date. The LPN confirmed during interviews that the medications were not dated as required. Additionally, the LPN left a medication cart unlocked and unattended in the hallway while administering medication to a third resident. The computer on top of the cart, displaying the resident's Medication Administration Record (MAR), was also left open and visible. The cart was not within the LPN's line of sight during this time. Both the LPN and the Director of Nursing acknowledged during interviews that the cart should have been locked and the medications and MAR secured according to facility policy.
Incorrect Insulin Administered Due to Medication Verification Failure
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes and morbid obesity, who was cognitively intact, received the wrong type of insulin during medication administration. The resident had a physician's order for insulin aspart to be administered before meals for hyperglycemia, but instead, an LPN administered 5 units of Basaglar KwikPen, a long-acting insulin, in error. The medication administration record (MAR) incorrectly documented that insulin aspart had been given, and the LPN was unable to locate the prescribed insulin aspart in the medication cart, finding only Basaglar and insulin lispro pens available. The facility's policy required verification of the right medication, dose, route, time, and resident identity before administration, but these procedures were not followed in this instance. The LPN did not realize the error at the time of administration and only became aware after review and questioning by the surveyor. The incident was confirmed through observation, record review, and staff interviews, with the LPN acknowledging the mistake and the MAR's inaccuracy.
Failure to Follow Infection Control Practices During Medication Administration and Pericare
Penalty
Summary
Staff failed to follow proper infection prevention and control practices for four residents, as observed by surveyors. An LPN did not perform hand hygiene before preparing or after administering medications to three residents, despite the facility's policy requiring hand hygiene before donning gloves and after removing them. The LPN confirmed during an interview that hand hygiene was not completed between residents during medication preparation and administration. The Infection Preventionist also indicated that hand hygiene should have been performed between residents, either by washing hands or using alcohol-based sanitizer. Additionally, a CNA was observed placing clean wash cloths in an unsanitized sink, running water over them, wringing them out, and hanging them over the side of the sink before using them to provide pericare to a resident. The CNA acknowledged that the sink was not sanitized prior to use and stated that a basin is only used for in-bed care, not in the bathroom. The Director of Nursing confirmed that staff should use a basin or wipes for pericare, in line with facility policy. However, the facility's Activities of Daily Living policy, which was the only pericare policy available, did not specify the use of a basin or wipes during pericare.
Resident's Call Light Request for Coffee Unmet in Timely Manner
Penalty
Summary
The facility failed to ensure timely assistance for a resident's request, resulting in a deficiency. On the morning of February 26, 2025, a resident with diagnoses including spinal stenosis, type 2 diabetes mellitus, COPD, anxiety, and chronic pain syndrome, activated their call light at 6:46 AM to request a cup of coffee. The resident, who had intact cognition and required setup assistance for eating, was observed by the surveyor to have their call light turned off by a CNA at 7:12 AM without receiving the requested coffee. The resident expressed that it was common to wait a long time for staff to respond to call lights, sometimes up to two hours. The CNA confirmed turning off the call light and not providing coffee due to instructions from dietary staff that CNAs could not provide coffee directly. The dietary staff had recently changed the procedure, requiring CNAs to use a radio to request coffee from the kitchen, as a carafe of coffee was no longer provided to the unit. The dietary manager confirmed this change and indicated that coffee could be sent ahead of meal trays if requested. The Director of Nursing stated that a resident's call light should remain on until their need is met, highlighting a lapse in communication and procedure adherence that led to the resident's unmet request.
Failure to Consistently Obtain Daily Weights for Residents
Penalty
Summary
The facility failed to provide necessary care and treatment to maintain the highest practicable well-being for two residents, R7 and R10, by not consistently completing daily weights as ordered. R7, who has diagnoses including congestive heart failure (CHF) and diabetes, had 44 missing daily weights from 11/10/24 to 2/25/25. R7's care plan required daily weights to monitor fluid volume due to CHF and venous insufficiency, but these were often missed due to insufficient staff to perform the necessary two-assist transfer before breakfast. R7 confirmed that weights were frequently missed, and staff interviews corroborated the lack of staffing as a reason for the missed weights. Similarly, R10, with diagnoses of high blood pressure and chronic venous insufficiency, had 64 missing daily weights from 10/9/24 to 2/26/25. R10's care plan also required daily weights to monitor for significant changes, but these were not consistently obtained due to staffing shortages. Interviews with staff, including a Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant, confirmed that the lack of staff made it difficult to complete daily weights for residents requiring two staff for mechanical lift transfers. The Nurse Practitioner and Director of Nursing acknowledged the issue, noting that weights were missed and that staff needed prompting to follow physician orders.
Inadequate Staffing Leads to Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R9 and R10, by not consistently following their care plans for mechanical lift transfers. R9, who has quadriplegia, diabetes, and hypotension, was supposed to be transferred with the assistance of two staff members using a full-body (Hoyer) lift. However, R9 reported that there were instances when only one staff member attempted to assist with the transfer, leading to delays in care due to insufficient staffing. R9 expressed feeling unsafe during these attempts and refused the transfer when only one staff member was present. Similarly, R10, who has high blood pressure and chronic venous insufficiency, required assistance from two staff members for transfers using a sit-to-stand (EZ Stand) lift. Despite this requirement, R10 reported that only one staff member assisted with the transfers. Interviews with staff, including an LPN and a CNA, confirmed that mechanical lift transfers were often conducted with only one staff member due to staffing shortages. The Director of Nursing acknowledged that the care plans for R9 and R10 required two staff members for safe transfers, which was not consistently adhered to.
Inaccurate and Incomplete Nursing Staff Postings
Penalty
Summary
The facility failed to maintain accurate and complete daily nursing staff postings, which had the potential to affect all 68 residents. The postings did not reflect actual hours worked by staff, as they included full shift hours even when staff worked partial shifts. For instance, the posting for the 10:00 PM to 6:00 AM shift inaccurately indicated that three CNAs worked a total of 22.5 hours, despite some CNAs only working partial shifts. Additionally, the facility did not retain these postings for the required 18 months, instead providing printed versions without edits for staffing changes. The surveyor's review of the facility's nursing staff postings and schedules revealed discrepancies, such as listing staff under full shift rows when they only worked partial shifts. The Nursing Home Administrator confirmed that the data for postings was pulled from a computer program and that original postings were not retained. The Staffing Coordinator also confirmed that postings were not updated to reflect schedule changes, such as call-ins or partial shifts. This lack of accurate and retained documentation was identified through observations, staff interviews, and record reviews.
Failure to Maintain CPAP/BiPAP Machines
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents who required CPAP or BiPAP machines. The facility did not adhere to the manufacturer's instructions and its own policy regarding the cleaning and maintenance of these machines. Specifically, the facility did not replace the filters on the CPAP and BiPAP machines as recommended by the manufacturer, which is crucial for maintaining the effectiveness and hygiene of the equipment. Resident 3, who had diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea, used a CPAP machine regularly. However, the filter on the machine was observed to be dark and dirty, indicating it had not been changed as required. Resident 49, with severe cognitive impairment and a history of sleep apnea, also had a BiPAP machine with a filter that appeared dirty and contained dust and hair. Both residents expressed concerns about the cleanliness of their machines, and there were no orders in place to check and change the filters. Similarly, Resident 22, who had chronic respiratory failure and used a BiPAP machine, and Resident 27, who used a CPAP machine, also had issues with filter maintenance. The filters on their machines were observed to be unsanitary, and in the case of Resident 27, the CPAP machine was missing a filter entirely. The Director of Nursing confirmed the lack of proper maintenance and the absence of supplies to change the filters, acknowledging the deficiency in care provided to these residents.
Failure to Follow Prescribed Diet Serving Sizes
Penalty
Summary
The facility failed to ensure that menu serving sizes were followed for therapeutic and mechanically altered diets for five residents. Specifically, the staff served smaller portions than indicated on the extended menu for residents who required double protein and those prescribed mechanically altered diets. The facility's policy required that all diets be prescribed by the attending physician and reviewed by a dietitian for accuracy and therapeutic goals. However, the surveyor observed that the dietary staff did not adhere to these requirements, leading to discrepancies in the serving sizes provided to the residents. Resident 69, who was dependent on hemodialysis and required a double protein diet, was not served the correct portion size as per the dietitian's assessment. Similarly, residents with diagnoses such as dysphagia, malignant neoplasm of the tonsil, and cerebral palsy, who required mechanically altered diets, were served with a smaller scoop than specified. The Dietary Manager confirmed that the meal tickets and care plans were not updated to reflect the correct diet orders, resulting in the residents not receiving the appropriate portion sizes as per their dietary needs.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R54, had a self-administration of medication assessment or a physician's order to self-administer medication. On two separate occasions, a surveyor observed medication, specifically a bottle of 12% ammonium lactate lotion, left at R54's bedside. R54, who had intact cognition as indicated by a BIMS score of 13 out of 15, confirmed self-administering the lotion without staff assistance. However, the resident's medical record did not contain the necessary documentation for self-administration of medication. The facility's policy requires a licensed nurse to complete a screen to determine factors impacting safe medication administration and a physician's order for self-administration. Additionally, medications to be self-administered should be secured in a locked area or stored in the medication cart. The Director of Nursing confirmed that R54 did not have the required assessment or order and acknowledged that medication should not be stored on a resident's bedside table. Consequently, the medication was removed from R54's room by a registered nurse as per the Director of Nursing's instructions.
Failure to Enforce Smoking Policy for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident known to smoke. The resident, who had intact cognition and was assessed as needing the facility to store their smoking materials, was observed with cigarettes and a lighter in their wheelchair. This was contrary to the facility's Smoking and E-Cigarettes Policy, which required all smoking materials to be stored at the nurses' station and prohibited in resident rooms. Despite the policy and the resident's smoking care plan stating that smoking materials should be stored with staff, the resident was allowed to keep these items on their person. The deficiency was further highlighted when the resident was observed self-propelling their wheelchair with smoking materials in the cup holder, and the Assistant Director of Nursing confirmed that residents were not supposed to keep cigarettes and lighters. The Director of Nursing acknowledged that the resident had a history of giving cigarettes to other residents and confirmed that the resident was not supposed to have smoking materials on their person. Despite this, the resident was again observed with a lighter in their wheelchair cup holder, indicating a failure to enforce the facility's smoking policy and ensure the resident's environment was free from potential hazards.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for two residents with indwelling catheters. The facility's policies required catheter bags to be covered and not in contact with the floor to prevent infection. However, observations revealed that the catheter drainage bags of two residents, R47 and R49, were uncovered and in contact with the floor. R47, who had intact cognition, was observed on two occasions with the catheter bag visible from the hallway and touching the floor. Similarly, R49, who had severely impaired cognition, was observed with the catheter bag on the floor, and an empty basin nearby, which the resident stated staff sometimes used to place the bag. The Director of Nursing confirmed that catheter bags should not be on the floor due to infection control issues and that staff were expected to cover the bags for dignity. Despite this, a Certified Nursing Assistant was observed leaving R49's room without addressing the catheter bag's position on the floor. The facility's failure to adhere to its catheter care policies and procedures contributed to the deficiency in preventing urinary tract infections for these residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for three residents, leading to deficiencies in medication management. For one resident, a nurse administered Basaglar insulin with a dosage discrepancy between the medication bag label and the Medication Administration Record (MAR). The nurse acknowledged that the label should have been updated, and the Director of Nursing (DON) confirmed the label should reflect the correct dose. Another resident received Systane Ultra Ophthalmic Solution without an open date on the bottle or carton, which the nurse and DON verified should have been labeled with the opening date. Additionally, a third resident had wound care treatment solutions, including Dakin's solution, Vashe wound therapy solution, and acetic acid, stored on their bedside table, contrary to the facility's policy. The resident confirmed the bottles were used daily for wound cleaning, and the DON verified that these medications should not be stored at the bedside without an order. The DON instructed staff to remove the medications from the resident's room, indicating a lapse in adherence to medication storage policies.
Inadequate Infection Control Measures for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for two residents, R51 and R54. R51, who had wounds requiring care, was not placed on EBP, and there was no EBP sign on or near the entrance to R51's room. Despite having wounds on the left leg and abdomen, which required daily dressing changes, the necessary precautions were not communicated to staff, as confirmed by the Director of Nursing (DON). The absence of an EBP sign meant that staff were likely unaware of the need to don personal protective equipment (PPE) when providing care to R51, contrary to the facility's policy. Similarly, R54, who had an indwelling catheter, was not initially placed on EBP, and there was no EBP sign on or near the room entrance. During an interview, a Certified Nursing Assistant (CNA) acknowledged that R54 should have been on EBP and that staff should have been wearing PPE during care. The DON confirmed that R54 should have been on EBP and that the Infection Preventionist should ensure compliance with the facility's EBP policy. The oversight in implementing EBP for these residents indicates a lapse in the facility's infection control measures.
Failure to Administer PCV20 Vaccine After Resident Consent
Penalty
Summary
The facility failed to administer the PCV20 vaccine to a resident who had consented to receive it. The resident, who had intact cognition and no activated power of attorney for healthcare, signed a consent form on October 11, 2023, indicating their desire to receive the PCV20 vaccine. However, the medical record did not show that the vaccine was administered. During an interview, the resident confirmed that they had signed the consent form but had not received the vaccine. The Assistant Director of Nursing (ADON) acknowledged that the consent form was likely filled out incorrectly by staff, leading to the oversight. The ADON confirmed that if consent was received for a vaccine offered by the facility, it should have been administered. The Nursing Home Administrator also stated that staff are expected to offer vaccines per CDC recommendations and the facility's policy, and that the resident should have received the vaccine if they consented to it.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Green Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brown Cty Comm Treatment Ctr-bayshore Village | 0.7 mi | ★★★★★ | 0 | 0 |
| Odd Fellow Home | 4.4 mi | ★★★★★ | 5 | 0 |
| Grancare Nursing Center | 5.9 mi | ★★★★★ | 6 | 0 |
| Green Bay Health Services | 6.2 mi | ★★★★★ | 0 | 0 |
| Ccc Of West Green Bay | 6.5 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Edenbrook Of Green Bay.
100% money-back within 48 hours.
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.