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Deficiency Records for Edenbrook of Oshkosh

A list of the most recent deficiencies for Edenbrook of Oshkosh. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Edenbrook of Oshkosh. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Allow residents to self-administer drugs if determined clinically appropriate. Health 2024-08-21 2024-09-20 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-08-21 2024-09-20 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-08-21 2024-09-20 Y
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. Health 2024-08-21 2024-09-20 Y
Provide and implement an infection prevention and control program. Health 2024-08-21 2024-09-20 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-08-21 2024-09-20 Y
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. Health 2024-02-06 2024-03-06 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-02-06 2024-03-06 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-02-06 2024-03-06 N
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. Health 2024-02-06 2024-03-06 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-02-06 2024-03-06 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2024-02-06 2024-03-06 N
Establish policies and procedures for sheltering. Fire Safety 2024-02-06 2024-03-06 N
Establish methods for sharing information. Fire Safety 2024-02-06 2024-03-06 N
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. Fire Safety 2024-02-06 2024-03-06 N
Have corridors or aisles that are unobstructed and are at least 8 feet in width. Fire Safety 2024-02-06 2024-03-06 N
Have exits that are accessible at all times. Fire Safety 2024-02-06 2024-03-06 N
Install proper backup exit lighting. Fire Safety 2024-02-06 2024-03-06 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-02-06 2024-03-06 N
Provide properly protected cooking facilities. Fire Safety 2024-02-06 2024-03-06 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-02-06 2024-03-06 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-02-06 2024-03-06 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-06 2024-03-06 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-02-06 2024-03-06 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-02-06 2024-03-06 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-02-06 2024-03-06 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-02-06 2024-03-06 N
Provide a written emergency evacuation plan. Fire Safety 2024-02-06 2024-03-06 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-02-06 2024-03-06 N
Have restrictions on the use of highly flammable decorations. Fire Safety 2024-02-06 2024-03-06 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2024-02-06 2024-03-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-02-06 2024-03-06 N
Have proper medical gas storage and administration areas. Fire Safety 2024-02-06 2024-03-06 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-01-25 2023-02-23 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-01-25 2023-02-23 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-01-23 2023-02-23 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-01-23 2023-02-23 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-01-23 2023-02-23 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-01-23 2023-02-23 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-01-23 2023-02-23 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-01-23 2023-02-23 N
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Fire Safety 2023-01-23 2023-02-23 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-02-16 2022-03-16 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2022-02-16 2022-03-16 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-02-16 2022-03-16 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-02-16 2022-03-16 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-02-16 2022-03-16 N
Provide appropriate foot care. Health 2022-02-16 2022-03-16 N
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. Health 2022-02-16 2022-03-16 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-02-16 2022-03-16 N
Ensure staff are vaccinated for COVID-19 Health 2022-02-16 2022-03-16 N
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. Fire Safety 2022-02-15 2022-03-16 N
Install proper backup exit lighting. Fire Safety 2022-02-15 2022-03-16 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-02-15 2022-03-16 N
Provide properly protected cooking facilities. Fire Safety 2022-02-15 2022-03-16 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2022-02-15 2022-03-16 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-02-15 2022-03-16 N
Properly install and monitor supervisory attachments on automatic sprinkler systems. Fire Safety 2022-02-15 2022-03-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-02-15 2022-03-16 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-02-15 2022-03-16 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-02-15 2022-03-16 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-02-15 2022-03-16 N
Have proper openings in smoke barrier doors. Fire Safety 2022-02-15 2022-03-16 N
Have restrictions on the use of portable space heaters. Fire Safety 2022-02-15 2022-03-16 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2022-02-15 2022-03-16 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-02-15 2022-03-16 N
Have correct number of accessible exits for each story. Fire Safety 2024-02-06 Not Fixed N

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