Inspection visit
Inspection
Citations
12 citations recorded*CMS
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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0362GeneralS&S Epotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the August 27, 2025 survey of Edenbrook of Green Bay?
This was a inspection survey of Edenbrook of Green Bay on August 27, 2025. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Edenbrook of Green Bay on August 27, 2025?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.