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Public Record

Edenbrook of Oshkosh

Nursing HomeOshkosh, WICMS 525299
76 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
110

*CMS

Avg. residents per day
68.8

*CMS

Inspection record

On record from CMS

Citations on record
76

*CMS

Inspections on file
10

*CMS

Last inspection
2025-11-25

*CMS

Citations

76 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0804Generalpotential for harm

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

  • 0812Generalpotential for harm

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

  • 0809Generalpotential for harm

    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.

  • 0690Generalpotential for harm

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

  • 0770Generalpotential for harm

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

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0004Generalpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0241Generalpotential for harm

    Have correct number of accessible exits for each story.

  • 0657Generalpotential for harm

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

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0883Generalpotential for harm

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

  • 0584Generalpotential for harm

    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.

  • 0688Generalpotential for harm

    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.

  • 0291Generalpotential for harm

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

  • 0321Generalpotential for harm

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

  • 0341Generalpotential for harm

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

  • 0345Generalpotential for harm

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

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0372Generalpotential for harm

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

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0521Generalpotential for harm

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

  • 0006Generalpotential for harm

    Conduct risk assessment and an All-Hazards approach.

  • 0013Generalpotential for harm

    Develop Emergency Preparedness policies and procedures.

  • 0020Generalpotential for harm

    Establish policies and procedures including evacuation.

  • 0222Generalpotential for 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.

  • 0711Generalpotential for harm

    Provide a written emergency evacuation plan.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0741Generalpotential for harm

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

  • 0914Generalno actual harm

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

  • 0918Generalpotential for harm

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

  • 0553Generalpotential for harm

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

  • 0559Generalpotential for harm

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

  • 0921Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0761Generalpotential for harm

    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.

  • 0755Generalpotential for harm

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

  • 0554Generalpotential for harm

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

  • 0607Generalpotential for harm

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

  • 0711Generalpotential for harm

    Provide a written emergency evacuation plan.

  • 0584Generalpotential for harm

    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.

  • 0222Generalpotential for 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.

  • 0232Generalpotential for harm

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

  • 0241Generalpotential for harm

    Have correct number of accessible exits for each story.

  • 0271Generalpotential for harm

    Have exits that are accessible at all times.

  • 0741Generalpotential for harm

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

  • 0753Generalpotential for harm

    Have restrictions on the use of highly flammable decorations.

  • 0911Generalpotential for harm

    Meet requirements for the installation and maintenance of electrical systems.

  • 0918Generalpotential for harm

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

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0018Generalpotential for harm

    Establish procedures for tracking staff and patients during an emergency.

  • 0022Generalpotential for harm

    Establish policies and procedures for sheltering.

  • 0033Generalpotential for harm

    Establish methods for sharing information.

  • 0281Generalpotential for harm

    Install proper backup exit lighting.

  • 0321Generalpotential for harm

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

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0341Generalpotential for harm

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

  • 0345Generalno actual harm

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

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372Generalpotential for harm

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

  • 0374Generalpotential for harm

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

  • 0521Generalpotential for harm

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

  • 0690Generalpotential for harm

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

  • 0755Generalpotential for harm

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

  • 0803Generalpotential for harm

    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.

  • 0812Generalpotential for harm

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

  • 0698Generalpotential for harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0521Generalpotential for harm

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

  • 0372Generalpotential for harm

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

  • 0355Generalpotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0927Generalpotential for harm

    Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

  • 0341Generalpotential for harm

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

  • 0686Generalpotential for harm

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

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Edenbrook of Oshkosh?
Edenbrook of Oshkosh is a Medicare- and Medicaid-certified nursing home in Oshkosh, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525299.
What is the CMS rating for Edenbrook of Oshkosh?
Edenbrook of Oshkosh has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Edenbrook of Oshkosh have?
Edenbrook of Oshkosh is certified for 110 beds. It serves an average of 68.8 residents per day.
How many citations does Edenbrook of Oshkosh have?
Edenbrook of Oshkosh has 76 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Edenbrook of Oshkosh last inspected?
Edenbrook of Oshkosh was last inspected on November 25, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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