Inspection Reports for Edenbrook of Green Bay

The inspection was conducted to assess compliance with regulatory requirements related to resident dignity during meals, appropriate treatment and care according to orders, staffing qualifications in food and nutrition services, and infection prevention and control programs.

The facility was found deficient in maintaining resident dignity during meal assistance, failing to notify providers of significant weight gains in residents with heart failure, employing an uncertified dietary manager, and not properly implementing infection prevention and control protocols including appropriate use of personal protective equipment (PPE) and signage for residents on isolation or enhanced barrier precautions.

The inspection was conducted due to a complaint regarding the facility's failure to provide timely pain medication to a resident receiving Hospice services.

The facility did not ensure timely administration of PRN morphine pain medication for one resident, resulting in a delay of approximately two hours. Staff interviews and record reviews confirmed the delay and identified communication and procedural issues contributing to the deficiency.

The complaint investigation found that resident R4, who received Hospice services and had orders for PRN morphine, experienced a delay of approximately two hours in receiving pain medication on either 7/8/25 or 7/20/25. The delay was confirmed through resident and staff interviews and medical record review. A grievance was initiated, and staff education was planned to address the issue.

The inspection was conducted due to a complaint investigation regarding medication administration errors, medication storage practices, and infection control procedures at Edenbrook of Green Bay.

The facility failed to provide accurate and safe medication administration for one resident, improperly stored medications without proper dating, left medication carts unlocked and unattended, and did not ensure proper hand hygiene and infection control practices for multiple residents.

The complaint investigation found substantiated issues including medication errors, improper medication storage, unlocked medication carts, and inadequate infection control practices.

The inspection was conducted based on complaints regarding delayed assistance with resident requests, inconsistent completion of daily weights for residents with heart failure, inadequate supervision for mechanical lift transfers, and inaccurate nursing staff postings.

The facility failed to provide timely assistance to a resident requesting coffee, did not consistently complete daily weights as ordered for two residents with congestive heart failure, did not ensure mechanical lift transfers were performed with the required two staff members, and did not maintain accurate or retained nursing staff postings.

The complaint investigation substantiated issues including delayed response to a resident's call light request, missed daily weights for residents with CHF, unsafe mechanical lift transfers without required staff assistance, and inaccurate nursing staff postings that were not retained as required.

The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident safety, catheter care, respiratory care, medication labeling and storage, nutrition, infection prevention, and vaccination policies.

The facility was found deficient in multiple areas including failure to ensure proper self-administration of medication assessments and orders, unsafe storage of smoking materials, improper catheter care leading to infection risks, inadequate cleaning and maintenance of CPAP/BiPAP machines, improper medication labeling and storage, failure to serve correct therapeutic diet portions, lack of enhanced barrier precautions for residents with wounds or catheters, and failure to administer pneumococcal vaccine despite resident consent.

The inspection was conducted due to a complaint investigation regarding an allegation that Resident 1 (R1) sexually assaulted Resident 2 (R2) at the facility.

The facility did not permit immediate access to a resident by a representative of the protection and advocacy systems and denied access to resident information to Adult Protective Services (APS) and the Department of Corrections (DOC). Interviews revealed that R2 reported inappropriate sexual touching by R1, and staff failed to report or fully cooperate with APS and DOC representatives. The facility acknowledged the incident and confirmed that R1 was arrested following a warrant issued by the probation officer.

The complaint involved an allegation that R1 sexually assaulted R2. APS was notified and attempted to investigate but was denied access to R2 and resident information. The facility staff stated R2 wanted to remain anonymous and did not allow APS to interview R2. The probation officer also was denied access to R2's name and could not obtain a statement from the victim. The facility reported the crime to police, resulting in a warrant for R1's arrest.

The inspection was conducted due to complaints regarding failure to notify resident representatives of changes in condition and treatment, failure to provide care according to physician orders, and failure to provide timely laboratory services.

The facility failed to notify resident representatives of changes in condition and treatment for 2 residents, did not follow physician orders for blood sugar management and PICC line care for 2 residents, and did not provide timely laboratory services for 1 resident. These failures resulted in minimal to actual harm to residents.

The complaint investigation found substantiated issues related to failure to notify resident representatives of changes in condition and treatment, failure to follow physician orders for blood sugar and PICC line care, and failure to provide timely laboratory services.

The inspection was conducted to assess compliance with care standards related to activities of daily living assistance and pain management for residents.

The facility failed to provide oral hygiene assistance to one resident (R44) who required help due to physical limitations, and failed to provide effective pain management for another resident (R216) during the initial days post-surgery due to delays in medication availability.

The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, and food safety practices at Edenbrook of Green Bay.

The facility was found deficient in providing oral hygiene assistance to a resident, ensuring effective pain management for another resident, monitoring adverse effects of high-risk medications, and maintaining safe food handling and sanitation practices. Food items were found unlabeled, past use-by dates, and refrigerators were not properly cleaned or monitored.