A list of the most recent deficiencies for Edenbrook of Oshkosh. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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. | Health | 2024-02-06 | 2024-03-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-06 | 2024-03-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-06 | 2024-03-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-02-06 | 2024-03-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-06 | 2024-03-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Establish methods for sharing information. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| 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. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-06 | 2024-03-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-25 | 2023-02-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-25 | 2023-02-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-01-23 | 2023-02-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-16 | 2022-03-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-16 | 2022-03-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-16 | 2022-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-16 | 2022-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-03-16 | N |
| Provide appropriate foot care. | Health | 2022-02-16 | 2022-03-16 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-02-16 | 2022-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-16 | 2022-03-16 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-16 | 2022-03-16 | N |
| 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. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Have proper openings in smoke barrier doors. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-15 | 2022-03-16 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2024-02-06 | Not Fixed | N |
