Edenbrook Of Oshkosh

Inspection findings

1. May 5, 2026 Health · 9 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0241 Egress Deficiencies

     Have correct number of accessible exits for each story.

     CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

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

     Corrected Jun 23, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 5, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jun 5, 2026 · CMS fire safety

2. Nov 25, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Dec 23, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0809 Nutrition and Dietary Deficiencies

     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.

     Corrected Dec 23, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Dec 23, 2025 · CMS health inspection

3. Jul 29, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Aug 16, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0770 Administration Deficiencies

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

     Corrected Aug 16, 2025 · CMS health inspection

4. Jul 1, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 31, 2025 · CMS health inspection

5. Mar 26, 2025 Fire Safety · 27 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected May 23, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0553 Resident Rights Deficiencies

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

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0559 Resident Rights Deficiencies

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

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

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

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0241 Egress Deficiencies

     Have correct number of accessible exits for each story.

     CMS fire safety

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0341 Smoke Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 29, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected May 21, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Apr 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Apr 26, 2025 · CMS fire safety

6. Aug 21, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Sep 20, 2024 · CMS health inspection

7. Feb 6, 2024 Fire Safety · 28 findings
   • Not serious Scope/severity F

     E0018 Emergency Preparedness Deficiencies

     Establish procedures for tracking staff and patients during an emergency.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0022 Emergency Preparedness Deficiencies

     Establish policies and procedures for sheltering.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0033 Emergency Preparedness Deficiencies

     Establish methods for sharing information.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     F0584 Resident Rights Deficiencies

     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.

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0803 Nutrition and Dietary Deficiencies

     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.

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0232 Egress Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0241 Egress Deficiencies

     Have correct number of accessible exits for each story.

     CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Mar 6, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• FEINSTEIN, DAN — 5% or greater direct ownership interest, 12%, since 09/01/2017
• LIFSICS, CHANNIE — 5% or greater direct ownership interest, 9%, since 09/01/2017
• LIFSICS, CHANNIE — operational/managerial control, NOT APPLICABLE, since 09/01/2017
• MAUER, DOVIE — operational/managerial control, NOT APPLICABLE, since 09/01/2017
• POLSTEIN, MORDECHAI — 5% or greater direct ownership interest, 16%, since 09/01/2017
• POLSTEIN, MORDECHAI — corporate officer, NOT APPLICABLE, since 09/01/2017
• RICE, PAMELA — operational/managerial control, NOT APPLICABLE, since 09/01/2017
• STESEL, MAXIM — 5% or greater direct ownership interest, 45%, since 09/01/2017
• WENDLING, CARRIE — w-2 managing employee, NOT APPLICABLE, since 09/01/2017