Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Omro during CMS and state inspections, most recent first.
A resident with a suprapubic catheter, history of UTIs, paraplegia with spina bifida, and moisture-associated skin damage was on Enhanced Barrier Precautions (EBP) per facility policy, which required staff to wear gowns and gloves during high-contact care such as bathing and dressing. A surveyor observed two CNAs bathe and dress the resident without wearing gowns. In interviews, both CNAs acknowledged they did not use gowns and stated PPE should be worn for residents on EBP, and the ADON and DON confirmed that gowns and gloves were required for bathing, grooming, and dressing under the EBP policy. This showed staff did not follow the facility’s infection prevention and control program requirements during the resident’s personal care.
Three residents at high risk for falls did not consistently receive required fall interventions, such as the use of two body pillows, and post-fall assessments were not accurately completed according to policy. Staff used outdated or incorrect vital signs in documentation, and some were unaware of specific care plan requirements, as confirmed by the DON.
Insufficient CNA Staffing and Delayed Call Light Response: The facility did not maintain staffing levels consistent with its census, Facility Assessment, and resident acuity. Staff and residents reported that weekends were especially difficult, with many residents needing 2-person assist transfers, delayed morning care, late meals, and call lights taking up to an hour to be answered. Surveyors also observed call lights being turned off before the resident’s need was met and multiple call lights activated at the same time while staff struggled to keep up.
Inaccurate POAHC Document: A resident with intact cognition and diagnoses including paranoid schizophrenia, anxiety, CHF, and chronic pain had a POAHC naming three individuals who were no longer consistent with the resident’s wishes. Surveyors found the named agents were not on the resident’s contact list, and the resident stated the facility did not review the document to ensure it was accurate. The SSD said POAHC documents were not reviewed at set intervals, and the NHA confirmed residents’ POAHC documents should be accurate.
Two residents did not receive bathing assistance in a timely and consistent manner as directed by their care plans. One resident with hemiplegia and chronic pain missed scheduled weekly showers, with staff documenting a refusal even though the resident and a CNA stated the shower was not offered. Another resident with schizophrenia, anxiety, and chronic pain did not consistently receive the ordered 2 full bed baths weekly, and the bathing record included NA and blank entries instead of consistent documentation.
A medication cart was left unlocked and unattended during a medication pass, contrary to the facility's policies. An LPN admitted to forgetting to lock the cart, which was observed by a surveyor. The DON confirmed that carts should be locked when not in use.
A facility failed to maintain proper infection control during medication administration. An LPN did not perform hand hygiene before preparing medications for four residents and failed to sanitize hands before and after glove use. Additionally, an RN did not disinfect a blood pressure cuff between uses for two residents, one of whom was on infection precautions. These actions were contrary to the facility's policies and CDC guidelines.
The facility failed to assess three residents for the ability to self-administer medications and did not obtain physician orders for this practice. Medications were left by nursing staff for these residents to self-administer without the required assessments or orders, despite the residents having intact cognition and being responsible for their healthcare decisions. The Director of Nursing confirmed the lack of necessary documentation, resulting in a deficiency.
A resident with multiple diagnoses, including spastic quadriplegic cerebral palsy and cognitive communication deficit, was observed without a call light within reach, contrary to their care plan. The resident confirmed they could not reach the call light and would call out for help. A CNA placed the call light in the resident's lap after being interviewed by a surveyor. The DON confirmed that call lights should be accessible to residents.
A resident with a documented allergy to Zofran was administered the medication twice due to a failure in communication and verification processes at the LTC facility. Despite the allergy being noted in the resident's records, the prescribing MD was not informed, and the pharmacy did not catch the error.
The facility failed to monitor the weights of two residents as ordered by their physicians, leading to a significant weight loss for one resident and a lack of weight documentation for another. Despite having specific orders for weight monitoring due to medical conditions, the facility did not consistently record weights or document reasons for missing weights, as acknowledged by the DON.
A registered nurse failed to perform proper hand hygiene while providing wound care to a resident with chronic obstructive pulmonary disease and open areas on the buttocks, which required enhanced barrier precautions. The nurse did not change gloves or cleanse hands between tasks, as confirmed by both the nurse and the DON.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy for a resident with a suprapubic catheter and other risk factors for infection. The facility’s EBP policy, dated March 2024, required the use of gowns and gloves during high-contact resident care activities, such as dressing and bathing, for residents at increased risk for multidrug-resistant organisms, including those with indwelling medical devices. The resident in question had a suprapubic catheter placed in November 2025 due to a history of urinary tract infections (UTIs), as well as paraplegia with lumbar and sacral spina bifida, and was being treated for moisture-associated skin damage in the sacral/peri-area. The resident had a recent hospitalization for a UTI, nosebleed, and suprapubic catheter dysfunction and was on EBP related to the suprapubic catheter. On the survey date, the surveyor observed two CNAs bathing and dressing this resident without wearing gowns, despite the resident being on EBP and the care activities qualifying as high-contact under the facility’s policy. Subsequent interviews confirmed that both CNAs did not wear gowns while providing this care. The CNAs acknowledged that PPE, including gowns, should be worn during high-contact care for residents on EBP. The ADON and DON both verified that staff were expected to wear gowns and gloves while bathing, grooming, and dressing residents on EBP. These observations and interviews demonstrated that staff did not implement the required EBP measures during personal care for this resident, resulting in a failure to maintain the infection prevention and control program as outlined in facility policy.
Failure to Implement Fall Interventions and Complete Accurate Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that fall interventions were consistently implemented and that post-fall assessments were accurately completed for three residents identified as being at high risk for falls. One resident, with severe dementia and a history of falls, had a care plan intervention requiring two body pillows in bed for comfort and safety, but was observed with only one pillow in use, while the second was left on a chair. The certified nursing assistant responsible was unaware of the need for a second pillow, indicating a lack of communication or training regarding the resident's care plan. Additionally, post-fall assessments for all three residents were not completed according to facility policy. The assessments often contained vital signs and pain evaluations that were either outdated or taken from other time periods, rather than being obtained at the time of each assessment as required. The Director of Nursing confirmed that staff had likely missed assessments and completed them in batches, sometimes using old or future-dated vital signs, which did not meet the policy's requirements for monitoring residents after a fall. The facility's own policies required individualized interventions to be implemented and post-fall assessments to be documented every shift for 72 hours, including relevant clinical findings such as vital signs, pain, and changes in function or cognition. However, the review of medical records and staff interviews revealed that these procedures were not followed, resulting in incomplete monitoring and documentation for residents who had experienced falls.
Insufficient CNA Staffing and Delayed Call Light Response
Penalty
Summary
The facility did not provide sufficient nursing staff to meet resident needs and did not consistently have staffing levels in accordance with its census or Facility Assessment. Survey review showed multiple days when the number of CNAs scheduled did not match the staffing plan, including weekends when staffing was lower and administrative staff were not available to assist on the floor. The Facility Assessment, updated [DATE], stated the average census was 32 and identified scheduling 8 CNAs per day, with 3 on the AM shift, 3 on the PM shift, and 2 on the NOC shift. The facility’s PBJ report also indicated concern with low weekend staffing. Interviews with the scheduler and DON showed staffing was based on census and acuity, but staff acknowledged the facility had higher acuity residents and many residents required 2-person assist transfers. The scheduler stated weekends were harder to staff and that ADON, scheduler, or other administrative staff would help on the floor if needed. The DON confirmed staffing concerns, including the prior two weekends, and stated the facility tried to ensure at least 3 CNAs were in the building, though residents and staff reported that 4 CNAs were often needed. Survey review of schedules showed several shifts with only 3 CNAs, 3.25 CNAs, or 3.5 CNAs scheduled, including weekends when census remained in the mid-30s. Resident, family, and staff interviews described delayed response to call lights, rushed care, and late meals. Residents reported waiting up to an hour for call lights to be answered, waiting 2.5 hours for care at shift change, and not being washed up timely. Staff reported that some residents required 2 staff for transfers, that some morning care took 30 minutes to an hour, and that breakfast was delayed on weekends, with staff still feeding residents late in the morning. During observations, surveyors saw multiple call lights activated at once, saw staff turn off a resident’s call light before the resident’s need was met, and observed a resident’s call light turned off after the resident requested assistance with washing. The DON stated call lights should remain on until staff return to complete the resident’s request and that staff were expected to answer call lights within 9 minutes.
Inaccurate POAHC Document
Penalty
Summary
The facility did not ensure that a Power of Attorney for Healthcare (POAHC) document was accurate for one resident. The resident was admitted with diagnoses including paranoid schizophrenia, generalized anxiety disorder, congestive heart failure, and chronic pain. The resident’s MDS assessment dated 8/29/25 showed a BIMS score of 15 out of 15, indicating intact cognition, and the resident was the own decision maker. Survey review of the resident’s medical record found a POAHC document signed on 6/8/12 naming three individuals as POAHC agents, but those individuals were not listed on the resident’s contact list. When interviewed, the resident stated that one named person was no longer a friend, another was also no longer a friend, and the resident was unsure about the third. The resident also stated a different individual who visits regularly should be added, and indicated the facility did not review the document with the resident to ensure it was accurate. The SSD stated there was no set interval for reviewing POAHC documents with residents, and the NHA confirmed residents’ POAHC documents should be accurate.
Inconsistent Bathing Assistance and Missed Showers
Penalty
Summary
The facility did not ensure assistance with activities of daily living, specifically bathing, was provided in a timely and consistent manner for 2 residents. The facility policy stated residents would be provided bathing or showering assistance and that refusals would be reported to the nurse, reapproached, and documented in the EMR. The deficiency involved one resident with hemiplegia, hemiparesis, chronic pain syndrome, limited mobility, and intact cognition, and another resident with paranoid schizophrenia, generalized anxiety disorder, chronic pain, and intact cognition who was his own decision maker. For the resident who was to receive a weekly Thursday PM shower, CNA documentation showed missed or inconsistent bathing entries across several months, including showers, bed baths, refusals, and entries marked NA. The resident stated he did not get a shower the week before last or on the scheduled Thursday PM shift and said he did not recall being offered a shower. He reported that staff stayed after the AM shift on 9/5/25 to give him a shower. The resident's family member, who worked at the facility, also stated the resident said he was not offered a shower. A CNA who worked the AM shift on 9/5/25 confirmed the resident said he was not offered a shower and that he also did not get one the prior week. Another CNA who documented the refusal stated she got to the resident too late, asked the nurse what to do, and then documented a refusal, adding that if she had arrived earlier the resident probably would have taken a shower. For the second resident, the care plan called for 2 full bed baths weekly, with sponge baths when a full bath or shower could not be tolerated, but the bathing record was inconsistent. CNA documentation showed varying numbers of full bed baths, with multiple scheduled days marked NA or left blank. The resident stated staff did not always wash him in the morning and did not always provide a second bed bath each week per his preference. The DON stated staff had been educated that NA should not be used for documentation and said that if staff could not shower a resident due to time constraints, they should tell the resident, ask the nurse to chart what occurred, and inform the resident the shower would be offered on the next shift or next day. The DON confirmed awareness that the first resident did not receive a shower.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in accordance with their policies, as observed during a medication pass. Specifically, one of the two medication carts was left unlocked and unattended in the hallway, with its drawers exposed, during the administration of medication to three residents. This incident occurred on the 100 wing of the facility and was observed by a surveyor. The facility's policies, dated January and February 2024, clearly state that medications should remain secured in a locked cabinet or cart unless in direct view of the individual administering the medication, and that medication carts should not be left unattended. During an interview, the LPN responsible for the cart acknowledged that it should not have been left open and unattended, admitting that they usually lock the cart but forgot on that day. The Director of Nursing also confirmed that medication carts should be locked when unattended.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene and equipment sanitization protocols. During medication administration, an LPN did not perform hand hygiene before preparing medications for four residents. The LPN also failed to complete hand hygiene before and after donning and doffing gloves during medication preparation. This lapse in protocol was observed for residents who were part of a sample of 12 residents. Additionally, an RN did not sanitize a blood pressure cuff between uses for two residents, one of whom was on evidence-based precautions for infection and had an indwelling catheter. The RN used the same cuff on both residents without disinfecting it, contrary to the facility's policy and CDC guidelines. Interviews with the LPN and the Director of Nursing confirmed the expectations for hand hygiene and equipment sanitization, which were not met during the observed incidents.
Failure to Assess Residents for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that three residents, identified as R6, R7, and R4, were assessed and had physician orders to self-administer medications. Observations by the surveyor revealed that medications were left by nursing staff for these residents to self-administer without the necessary assessments or orders. Specifically, LPN-D left a medication cup on R6's bedside table, and RN-E left medication cups on the tables of R7 and R4. None of these residents had documented assessments or physician orders authorizing them to self-administer their medications. The medical records of the residents involved indicated that all three had intact cognition, as evidenced by their BIMS scores of 15 out of 15, and were responsible for their healthcare decisions. Despite this, the facility's policy required a formal assessment and physician order for self-administration of medication, which was not completed for these residents. The Director of Nursing confirmed that the necessary assessments and orders were not in place for R6, R7, and R4, leading to the deficiency noted by the surveyor.
Resident Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident had a call light within reach, which is a deficiency in accommodating the needs and preferences of residents. On the specified date, a surveyor observed a resident, who was diagnosed with spastic quadriplegic cerebral palsy, generalized anxiety disorder, unspecified behavioral and emotional disorders, unspecified intellectual disabilities, muscle wasting and atrophy, and cognitive communication deficit, in their room without a call light within reach. The resident's Minimum Data Set (MDS) assessment indicated intact cognition with a BIMS score of 14 out of 15. The resident's pain care plan included an intervention to keep the call light within reach to assist in meeting needs and maintaining safety. During the observation, the resident was in a wheelchair in the middle of the room, and the call light was on the bed, out of reach. When asked by the surveyor, the resident confirmed they could not reach the call light and would call out for help if needed. A Certified Nursing Assistant (CNA) was interviewed and subsequently placed the call light in the resident's lap. The Director of Nursing (DON) confirmed that the call light should be on the resident's person or near them.
Failure to Communicate Allergy Leads to Medication Error
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured a resident's allergy was communicated before a medication order was made. A resident with severe cognitive impairment and a guardian for healthcare decisions was admitted with an allergy to Zofran, documented in both the hospital discharge summary and the facility's admission orders. Despite this, the resident was administered Zofran on two occasions. The facility's policy requires that medications be administered according to provider orders and verified for contraindications, including allergies. Interviews with facility staff revealed a breakdown in communication and verification processes. A registered nurse indicated that medication orders should be reviewed for allergies during phone calls with the medical doctor, and if a concern is identified, the order should be clarified. The director of nursing confirmed that the facility's medical record system should alert nurses to allergies when entering medication orders. However, the medical doctor who prescribed Zofran was not informed of the resident's allergy, and the pharmacy did not catch the error before the medication was administered.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure that two residents, R9 and R434, received the necessary care and services to prevent and monitor weight loss, as required by their physician's orders. R9, who had diagnoses including type 2 diabetes mellitus, abnormal weight loss, and unspecified protein-calorie malnutrition, experienced a significant weight loss of 14.29% over a 14-week period. Despite having a physician's order to be weighed three times a week, R9's weights were not consistently recorded, and there were several weeks with no weights documented. The Director of Nursing (DON) acknowledged that the nursing staff did not consistently enter progress notes when weights were not obtained, and there were issues with the current process of recording and monitoring weights. Similarly, R434, who was admitted with diagnoses including morbid obesity, type 2 diabetes, and dyskinesia of the esophagus, had a physician's order for daily weights due to congestive heart failure (CHF). However, after the initial weight was recorded upon admission, no additional weights were documented in R434's medical record. The DON confirmed that R434 should have been weighed multiple times following the initial weight, as per the physician's order. The failure to adhere to the prescribed weight monitoring protocols for both residents highlights a deficiency in the facility's care and services.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during the provision of care for a resident. The incident involved a registered nurse (RN-C) who did not adhere to the facility's hand hygiene policy while providing wound care to a resident with chronic obstructive pulmonary disease and open areas on both buttocks due to moisture-associated skin damage. These conditions placed the resident at high risk for infection, necessitating enhanced barrier precautions. During the care process, RN-C removed the old dressing from the resident's right buttock and cleansed both buttocks without changing gloves or performing hand hygiene. RN-C then applied new gloves and continued with the care procedure, again failing to change gloves or cleanse hands between tasks. This oversight was confirmed by both RN-C and the Director of Nursing (DON-B) during interviews, acknowledging missed opportunities for hand hygiene between dirty and clean tasks.
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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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Nursing homes near Omro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eden Rehab Suites And Green House Homes | 6.8 mi | ★★★★★ | 5 | 0 |
| Evergreen Health Center | 8.8 mi | ★★★★★ | 0 | 0 |
| Bethel Home | 9 mi | ★★★★★ | 11 | 1 |
| Juliette Manor | 10.3 mi | ★★★★★ | 2 | 0 |
| Edenbrook Of Oshkosh | 11.1 mi | ★★★★★ | 3 | 0 |
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