All citations for Edenbrook of Oshkosh

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Edenbrook of Oshkosh

Last standard health inspection on record

May 5, 2026

Showing 1 to 25 of 30 citations

  1. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  2. No harm, with potential for more than minimal harm

    Conduct risk assessment and an All-Hazards approach.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  3. No harm, with potential for more than minimal harm

    Develop Emergency Preparedness policies and procedures.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0013, Emergency Preparedness Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 23, 2025).

  4. No harm, with potential for more than minimal harm

    Establish policies and procedures including evacuation.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0020, Emergency Preparedness Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  5. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  6. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  7. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 29, 2025).

  8. No harm, with potential for more than minimal harm

    Provide a written emergency evacuation plan.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 21, 2025).

  9. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  10. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  11. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  12. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  13. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  14. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  15. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  16. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0511, Services Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  17. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0521, Services Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  18. No harm, with potential for more than minimal harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  19. No harm, with potential for more than minimal harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of July 29, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 16, 2025).

  20. No harm, with potential for more than minimal harm

    Provide timely, quality laboratory services/tests to meet the needs of residents.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0770, Administration Deficiencies. Inspection of July 29, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 16, 2025).

  21. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of July 1, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 31, 2025).

  22. No harm, with potential for more than minimal harm

    Allow resident to participate in the development and implementation of his or her person-centered plan of care.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0553, Resident Rights Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  23. No harm, with potential for more than minimal harm

    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0559, Resident Rights Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  24. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of March 26, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

  25. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of March 26, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 26, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.