Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oshkosh during CMS and state inspections, most recent first.
Surveyors found that food items were frequently unlabeled, undated, or improperly sealed, and food temperatures were not consistently documented before meals. Kitchen equipment and storage areas were observed to be unclean, with no cleaning schedule in place. The rehab unit refrigerator contained expired and undated items, and staff were unclear about cleaning responsibilities. During meal service, a cook failed to follow proper hand hygiene and glove use, handling ready-to-eat food after touching contaminated surfaces.
The facility did not serve meals according to posted times, with lunch service starting and trays being delivered significantly later than scheduled. A resident and a CNA confirmed that late meal service was a frequent issue, and the Dietary Manager was aware of the problem.
Three residents with type 2 diabetes who were prescribed consistent carbohydrate diets were served a full slice of garlic toast instead of the ordered half slice during a meal service. The dietary staff did not follow the tray card instructions, and the Dietary Manager confirmed that diet orders should be followed as written.
Two residents with Foley catheters did not have physician orders for monthly and as-needed catheter changes transcribed into their records, resulting in missed care. Additionally, one resident with an indwelling device was not placed on Enhanced Barrier Precautions as required, and appropriate signage and PPE were not provided.
A resident with severe cognitive impairment and multiple medical conditions experienced a delay in a scheduled medical procedure due to the facility's failure to send a completed pre-op H&P to the urology clinic and to obtain a required urine culture. The DON confirmed that staff did not notify the receiving facility about the incomplete order, resulting in a lack of continuity of care.
A resident who required assistance with dressing reported being left naked and unattended by a CNA after their gown became soiled during the night. The facility's investigation was incomplete, lacking interviews with key staff, failing to determine the duration the resident was left exposed, and not addressing why the resident used a phone instead of the call light. Additional resident interviews revealed concerns about staff rudeness and lack of respect for resident preferences.
A resident with multiple diagnoses and moderately impaired cognition, who ate all meals at the bedside table, was observed over several days to have a dirty bedside table with dried food and liquid stains that were not cleaned between meals. Staff were unclear about cleaning responsibilities, and the facility lacked a formal policy for ensuring a clean, home-like environment. The DON confirmed the table should be cleaned when visibly dirty, but this was not consistently done.
A resident with limited mobility and multiple chronic conditions did not consistently receive prescribed daily range of motion (ROM) exercises, and staff documentation was frequently incomplete or inaccurate. CNA staff often marked that ROM was not completed instead of recording resident refusals, and the DON confirmed that documentation should have reflected refusals when they occurred.
The facility failed to maintain sanitary conditions in utility rooms across all units, with surveyors observing dust, debris, stains, and odors of human waste. Uncovered trash containers and improper storage of PPE posed cross-contamination risks. The Nursing Home Administrator confirmed these issues, citing recent housekeeping staff turnover as a contributing factor.
The facility did not ensure two residents were assessed for safe self-administration of medication. An LPN left medication at their bedsides without the required physician orders, assessments, or care plans. One resident had moderately impaired cognition, while the other had intact cognition, but neither had the necessary documentation for self-administration. The DON confirmed the absence of these documents.
The facility did not implement its policies to prevent abuse and neglect by failing to conduct timely background checks for a CNA, referred to as CNA-F. Despite policy requirements, necessary DOJ and IBIS letters and reference checks were missing for CNA-F's direct employment period. The NHA confirmed these documents should have been completed before employment.
A resident received another's medication due to an LPN's error, and the facility failed to document required blood pressure checks and educate the LPN on medication administration protocols. The resident was asymptomatic, but the facility did not follow the physician's order for monitoring vital signs, and there was no record of the LPN receiving necessary education post-incident.
A facility failed to properly label and store medications for three residents. A nurse left a medication cup unattended, and another nurse used undated medication bottles and pens, contrary to facility policy. The Director of Nursing confirmed the labeling requirement.
A registered nurse failed to perform proper hand hygiene and did not wear gloves as required during medication administration for two residents. The nurse did not wash hands before administering medications and handled methimazole, a hazardous drug, without gloves. These actions were confirmed by the nurse and the Director of Nursing, highlighting deficiencies in the facility's infection prevention and control program.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, as observed during a survey. Multiple food items in the walk-in cooler, dry storage, and freezer were found unlabeled, undated, unsealed, or expired. Examples included bags of sliced ham and turkey with no labels or dates, a container of sour cream without an open date, and various bins and bags of food products that were not properly identified. The Dietary Manager confirmed that all food items should be sealed, labeled, and dated, but acknowledged ongoing issues with compliance in these areas. Food temperatures were not consistently documented prior to meal service, with several days missing required temperature logs for breakfast, lunch, or supper. The Dietary Manager confirmed that holding temperatures should be recorded before meals are served. Additionally, kitchen equipment and storage areas were not maintained in a clean condition. Observations included metal pans and bowls not stored upside down, a microwave with dried food debris, dust and debris on the floor, and a breakfast cart with dried cereal and wrappers that remained uncleaned for hours. There was also no cleaning schedule in place for the kitchen, and the Dietary Manager confirmed that many areas were not properly cleaned. The rehab unit refrigerator, used to store resident food, contained undated, expired, and unlabeled items, as well as visible crumbs, spills, and sticky substances. Staff were unclear about who was responsible for cleaning the refrigerator. During meal service, a cook was observed changing gloves multiple times without washing hands, touching their face mask with gloved hands, and then handling ready-to-eat food. The cook also used the same gloved hand to touch various surfaces and food items without proper hand hygiene. These actions were confirmed by both the cook and the Dietary Manager during interviews.
Delayed Meal Service and Untimely Tray Delivery
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner according to posted meal times and residents' needs and preferences. On the observed date, lunch service for multiple halls began later than scheduled, with Hall 4 starting at 11:45 AM instead of the posted 11:10 AM, and the meal cart not being sent to the unit until 12:00 PM. Similarly, Hall 2's meal service began at 12:07 PM, well after the scheduled 11:40 AM, and the meal cart was not sent to the unit until 12:30 PM. Certified Nursing Assistants did not begin delivering trays on Hall 2 until 12:43 PM, with the last tray delivered at 1:16 PM, significantly past the intended meal time. Resident and staff interviews confirmed that meal trays were frequently served late. One resident with intact cognition stated that trays should have been served earlier and that late service was a consistent issue. A CNA also confirmed the frequent lateness of meal service. The Dietary Manager acknowledged awareness of the ongoing problem and noted that they had recently started working full-time at the facility to address kitchen issues, having previously split time between two facilities.
Failure to Follow Prescribed Consistent Carbohydrate Diet Orders
Penalty
Summary
Three residents with diagnoses of type 2 diabetes were prescribed consistent carbohydrate diets, with specific meal orders indicating they should receive a half slice of garlic toast. During a meal service observation, the surveyor noted that these residents were instead served a full slice of garlic toast, contrary to their dietary orders. The tray cards for each resident, which the dietary staff referenced, clearly indicated the correct portion size, but this instruction was not followed. Interviews with the dietary staff member responsible for meal preparation revealed that the staff did not notice the tray card instructions specifying the half slice portion. The Dietary Manager confirmed that diet orders are to be followed as written. The facility's policy also states that residents on therapeutic diets should not receive food outside their prescribed orders unless approved by the appropriate clinical staff.
Failure to Transcribe Catheter Orders and Implement Enhanced Barrier Precautions
Penalty
Summary
Two residents did not receive appropriate care and services to prevent urinary tract infections (UTIs) due to failures in transcribing and implementing physician orders related to Foley catheter management. One resident, who was admitted with a chronic Foley catheter and a history of UTI, had hospital discharge instructions for monthly catheter changes and as-needed irrigation. These orders were not transcribed into the medical record or onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), as required by facility policy. The Director of Nursing confirmed that the order should have been transcribed and implemented, but it was not, and the physician was not notified for alternative orders. Another resident with a Foley catheter and a urology clinic order for monthly and as-needed catheter changes also did not have the order transcribed onto the MAR or TAR. This resident reported that the catheter had not been changed as ordered. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for this resident, who had an indwelling medical device, as required by facility policy. There was no EBP signage or personal protective equipment (PPE) available near the resident’s room, and staff initially indicated EBP was not needed, despite policy stating otherwise.
Failure to Provide Timely Laboratory Services and Complete Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to provide timely laboratory services and complete physician orders for a resident with multiple diagnoses, including dementia, traumatic ischemia/rhabdomyolysis, history of falls, and sick sinus syndrome. The resident, who had severely impaired cognition and an activated Power of Attorney for Healthcare, was scheduled for a urology procedure that required a pre-operative history and physical (H&P) and a urine culture. The urology clinic provided orders on 7/7/25, specifying that the H&P be completed within 30 days prior to the procedure and the urine culture be obtained on 7/11/25. The facility's provider completed the H&P on 7/8/25, but the document was not sent to the urology clinic as required. Additionally, nursing staff were unable to obtain the urine sample on the specified date because the resident left the facility that morning. The Director of Nursing confirmed that the facility did not notify the receiving facility about the incomplete order, which was necessary to ensure continuity of care and prevent a delay in the resident's surgical procedure.
Failure to Thoroughly Investigate Allegation of Resident Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident who reported being left naked and without a gown by a CNA during a night shift. The resident, who was cognitively intact and able to make their own healthcare decisions, required assistance with dressing and reported that after using a bedpan, their gown became soiled and was removed by the CNA, who then left the resident exposed and did not return. The resident used a phone to call for assistance instead of the call light, citing previous delays in staff response, and was eventually assisted by an RN with a clean gown several hours later. The facility's investigation into the incident was incomplete. The investigation did not include an interview or statement from the RN who assisted the resident, nor did it address why the resident used a phone instead of the call light. Additionally, the investigation failed to determine how long the resident was left without a gown or whether the resident was still exposed when the RN arrived. The education provided to staff following the incident did not cover customer service or dignity issues raised in the resident's grievance and was not provided to all staff who worked during the shift in question. Interviews with other residents revealed additional concerns about staff behavior, including rudeness, rushing care, and not respecting resident preferences, such as leaving lights on at night. The Nursing Home Administrator acknowledged that the concerns regarding the CNA constituted neglect and confirmed that the CNA was no longer employed at the facility. However, the investigation documentation lacked key details and did not fully address the scope of the resident's allegations or the related staff conduct.
Failure to Maintain Clean and Home-Like Environment for Resident
Penalty
Summary
Staff failed to maintain a clean and home-like environment for one resident, as evidenced by repeated observations of a dirty bedside tray table. The resident, who had multiple diagnoses including schizoaffective disorder, bipolar disorder, dementia, and limited physical mobility, was observed eating all meals at the bedside table with slow movements and required set-up assistance. Over several days, surveyors noted dried liquid stains and pieces of dried food on the bedside table, which were not cleaned between meals. Staff interviews revealed uncertainty about the cleaning schedule for bedside tables, and it was confirmed that the table should be wiped after each meal, especially since the resident used it for all meals. The facility lacked a formal policy regarding maintaining a clean, comfortable, and home-like environment, providing only an undated cleaning list that referenced cleaning over-bed tables. The Director of Nursing acknowledged that the bedside table should be cleaned when visibly dirty, but observations showed that this was not consistently done. The resident's medical record indicated moderately impaired cognition and a preference to eat in the room, further emphasizing the importance of maintaining cleanliness in the immediate environment.
Failure to Ensure and Accurately Document Range of Motion Program
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including schizoaffective disorder, dementia, muscle weakness, bilateral knee osteoarthritis, and peripheral vascular disease, did not consistently receive range of motion (ROM) exercises as outlined in their care plan. The care plan required daily ROM exercises, and therapy staff had trained nursing staff and provided exercise instructions in the resident's room. However, review of the medical record revealed inconsistent and inaccurate documentation of the ROM program. Over a nearly three-month period, there were multiple days with no documentation, days marked as 'not applicable,' and numerous days where staff indicated the ROM was not completed. Only a portion of days reflected that the exercises were performed, and a few days noted resident refusal. Interviews with staff revealed that a CNA frequently documented that ROM was not completed, rather than indicating when the resident refused the exercises. The CNA stated they were unaware of the option to document refusals. The Director of Nursing confirmed that daily and accurate documentation was required and that refusals should be properly recorded. These findings demonstrate that the facility did not ensure ROM exercises were completed or accurately documented according to the resident's care plan.
Unsanitary Conditions in Utility Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents across all three units. During a tour of the soiled utility rooms, surveyors observed significant cleanliness issues, including dust, debris, and stains on floors and walls, as well as odors of human waste. Uncovered trash containers with resident waste were noted, and there were risks of cross-contamination due to improper storage of personal protective equipment (PPE) in these areas. Additionally, surveyors found utility sinks filled with brown water and other soiled materials, further contributing to the unsanitary conditions. The surveyor's observations were confirmed by the Nursing Home Administrator (NHA), who acknowledged the issues and attributed them to recent turnover in the housekeeping department. The NHA provided cleaning schedules and checklists, which included tasks such as taking out the garbage from utility closets. However, the observed conditions indicated that these tasks were not being completed appropriately, leading to the deficiencies noted during the survey.
Failure to Assess Residents for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that two residents, R14 and R18, were assessed as able to safely and accurately self-administer medication. On the date of observation, an LPN left medication at the bedsides of R14 and R18 for them to self-administer without having the necessary physician orders, self-administration assessments, or care plans in place. This action was contrary to the facility's Medication Self Administration policy, which requires a licensed nurse to complete a screening to determine the safety of self-administration and mandates a physician order for residents deemed appropriate to self-administer medication. R14, who was admitted with diagnoses including diabetes, anemia, depression, and mild cognitive impairment, had a BIMS score indicating moderately impaired cognition. Despite this, R14 was left with gabapentin tablets to self-administer without the required documentation. Similarly, R18, with diagnoses including congestive heart failure, diabetes, and COPD, had intact cognition but also lacked the necessary physician order and assessment for self-administration. The Director of Nursing confirmed the absence of these critical documents for both residents.
Failure to Conduct Timely Background Checks for CNA
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and exploitation by not conducting thorough and timely background checks for a Certified Nursing Assistant (CNA), referred to as CNA-F. The facility's policy, revised on 10/4/23, mandates screening potential employees for any history of abuse, neglect, exploitation, or mistreatment, which includes obtaining information from previous employers and checking with licensing boards and registries. Additionally, a criminal background check is required for all prospective employees. However, during a review on 8/21/24, it was found that the facility did not have the necessary Department of Justice (DOJ) letter, Integrated Background Information System (IBIS) letter, and reference checks for CNA-F during their direct employment with the facility. CNA-F was initially hired on 12/21/23, left employment on 1/15/24, and returned as a contracted employee on 2/1/24. While DOJ and IBIS letters dated 2/1/24 and a Background Information Disclosure (BID) form dated 12/1/23 were provided, these documents were not available for CNA-F's direct employment period. Furthermore, a BID form was not provided for CNA-F's employment with the contracted staffing company. The Nursing Home Administrator (NHA) confirmed the absence of these documents, acknowledging that they should have been completed prior to CNA-F's employment with the facility.
Medication Administration Error and Lack of Documentation
Penalty
Summary
The facility failed to ensure the accurate administration of medication for a resident, identified as R2, who was one of eight sampled residents. On February 24, 2024, an LPN administered another resident's medication to R2, which included montelukast, Tylenol, atorvastatin, Protonix, and Lyrica. Following the medication error, the facility did not adhere to the physician's order to monitor R2's blood pressure every hour for four hours, as there was no documentation of blood pressures taken at 4:15 PM and 5:15 PM. The only recorded blood pressures were at 3:15 PM and 6:13 PM. Additionally, the facility did not provide documentation that the LPN involved in the medication error received education regarding the incident. The Director of Nursing, who was not present at the time of the incident, confirmed the absence of documentation for both the required blood pressure checks and the education of the LPN. The DON verified that the blood pressures should have been documented as per the physician's order and that the LPN should have been educated on the 5 rights of medication administration, which include ensuring the right person receives the medication.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were labeled and stored according to manufacturers' recommendations for three residents during a medication pass. For one resident, a registered nurse left a medication cup containing multiple medications unattended on the resident's bedside table while attending to another resident. This action was confirmed by the nurse, who acknowledged that medications should not be left unattended. The resident involved had intact cognition and a guardian for healthcare decisions, but there was no indication in the medical record that the resident could or wished to self-administer medication. Additionally, a licensed practical nurse administered medications to two residents using bottles and pens that were not labeled with open dates, contrary to the facility's policy. The nurse admitted that staff were instructed to date medication bottles when opened, but a former nursing manager had informed them it was unnecessary due to the manufacturer's expiration date. The Director of Nursing confirmed that medications should be labeled with an open date regardless of the manufacturer's expiration date.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN-D) during medication administration for two residents. On the specified date, RN-D did not perform proper hand hygiene before administering medications to both residents, R12 and R13. This lack of hand hygiene was observed by a surveyor during the medication preparation and administration process. Additionally, RN-D failed to adhere to the specific order to wear gloves when handling methimazole, a hazardous drug prescribed to R12 for hyperthyroidism. Instead, RN-D directly touched the medication with bare hands while preparing it for administration. Interviews conducted with RN-D and the Director of Nursing (DON-B) confirmed these observations. RN-D acknowledged the failure to perform hand hygiene before medication preparation and administration. DON-B verified the expectation for staff to complete hand hygiene at various stages of medication handling and confirmed that methimazole is a hazardous drug requiring gloves during handling. These lapses in infection control practices were identified as deficiencies in the facility's infection prevention and control program.
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 151 citations issued within 25 miles in the last 12 months — including the 5 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 Oshkosh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Health Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Park View Health Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Bethel Home | 2.6 mi | ★★★★★ | 11 | 1 |
| Eden Rehab Suites And Green House Homes | 4.6 mi | ★★★★★ | 5 | 0 |
| Edenbrook Omro | 11.1 mi | ★★★★★ | 35 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Edenbrook Of Oshkosh.
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.