Inspection Reports for Edenbrook of Oshkosh

The facility was found deficient in providing meals according to prescribed diets for 3 residents, serving meals late affecting more than 4 residents, and failing to store and prepare food in a safe and sanitary manner affecting all 72 residents. Issues included incorrect meal portions, late meal delivery, unlabeled and undated food items, improper food temperatures documentation, unclean kitchen equipment, and improper glove use during food service.

The facility failed to ensure appropriate catheter care and infection prevention for two residents, including failure to transcribe physician orders for Foley catheter changes and implement enhanced barrier precautions. Additionally, the facility did not complete timely laboratory services for one resident, resulting in a delayed medical procedure.

The complaint involved resident R2 alleging neglect by CNA-H on the 6/18/25 night shift, including being left naked and without a gown for a prolonged period. The complaint was substantiated with findings that the facility's investigation was incomplete and inadequate. CNA-H was terminated. Other residents reported related customer service issues.

The facility failed to thoroughly investigate the allegation of neglect involving resident R2. The investigation lacked interviews from key staff, did not address all aspects of the complaint including customer service and dignity issues, and did not include all staff working the relevant shift. CNA-H was terminated due to rudeness and neglect. Other residents also reported customer service issues with CNA-H.

The facility failed to ensure a clean and homelike environment for one resident, as evidenced by an unclean bedside tray table. Additionally, the facility did not ensure that range of motion exercises were completed or documented accurately for the same resident.

The facility was found deficient in multiple areas including failure to inform resident representatives of care conferences, lack of written notification for roommate changes, incomplete and outdated care plans, unsafe food storage and temperature monitoring, inadequate infection prevention and control practices including hand hygiene and enhanced barrier precautions, and failure to administer influenza and COVID-19 vaccines despite consent.

The facility was found deficient in multiple areas including failure to ensure residents were properly assessed and authorized to self-administer medications, incomplete caregiver background checks, medication administration errors without proper follow-up, improper labeling and storage of medications, inadequate infection control practices including hand hygiene and glove use, and unsafe, unsanitary conditions in utility rooms across all units.

The facility was found deficient in maintaining a safe, clean, and homelike environment, appropriate catheter care, safe medication administration, adherence to menu serving sizes, and proper food storage and cooling practices. Multiple areas had debris, structural damage, and inadequate housekeeping. One resident's catheter drainage bag was in contact with the floor. Medication was left at a resident's bedside without proper authorization. Food serving sizes did not meet menu specifications, and cooling temperatures were not properly documented.

The facility failed to ensure weekly wound assessments and consistent documentation of treatments for one resident with pressure ulcers, and did not maintain ongoing communication with a dialysis facility for one resident receiving dialysis. These deficiencies were verified through record reviews and staff interviews.