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 23 of 23 citations

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

    Establish procedures for tracking staff and patients during an emergency.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0018, Emergency Preparedness Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Establish policies and procedures for sheltering.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0022, Emergency Preparedness Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Establish methods for sharing information.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0033, Emergency Preparedness Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Provide properly protected cooking facilities.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Install a fire alarm system that can be heard throughout the facility.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0341, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  6. 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 February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

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

    Widespread (many residents). CMS level F.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  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 February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Have restrictions on the use of highly flammable decorations.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0753, Miscellaneous Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Meet requirements for the installation and maintenance of electrical systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0911, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  11. 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 February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  12. 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 February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

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

    Fire safety citation K-0232, Egress Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Have exits that are accessible at all times.

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

    Fire safety citation K-0271, Egress Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  15. 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.

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

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Install corridor and hallway doors that block smoke.

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

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

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

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  18. 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 February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  19. 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 February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Have correct number of accessible exits for each story.

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

    Fire safety citation K-0241, Egress Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    A waiver was granted.

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

    Install proper backup exit lighting.

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

    Fire safety citation K-0281, Egress Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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

    Have proper medical gas storage and administration areas.

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

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

  23. No harm, with potential for minimal harm

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

    Widespread (many residents). CMS level C.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of February 6, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 6, 2024).

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.