Oshkosh, WI

Eden Rehab Suites And Green House Homes

3-star overall rating with 3-star inspections with $13,886 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

3151 Eden Ct, Oshkosh, WI

(920) 651-4000

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

31

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2010-10-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.24

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.80

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.80

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

4.84

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

2.04

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

4.21

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.71

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.41

CMS adjusted RN staffing hours

Adjusted total hours

5.51

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

83%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

67%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,135

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

21.34

Composite VBP score used to determine payment impact.

Payment multiplier

0.9826

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.25% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.68

Baseline 6.71% · Performance 7.63% · Measure score 0.68 · Achievement 0.68 · Improvement 0

Total nurse turnover

0

Baseline 60.78% · Performance 79.63% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

7.85

Baseline 4.95 hours · Performance 5.31 hours · Measure score 7.85 · Achievement 7.85 · Improvement 3.87

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.15%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 160 · Observed rate 9.38% · Lower 95% interval 7.34%
Discharge to community	65.35%	50.57% 14.8 pts better	Better than the National Rate · Eligible stays 143 · Observed rate 62.94% · Lower 95% interval 58.62%
Medicare spending per beneficiary	0.59	1.02 0.4 pts better
Drug regimen review with follow-up	98.53%	95.27% 3.3 pts better	Numerator 67 · Denominator 68
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 68
Discharge self-care score	36.54%	53.69% 17.1 pts worse	Numerator 19 · Denominator 52
Discharge mobility score	9.62%	50.94% 41.3 pts worse	Numerator 5 · Denominator 52
Pressure ulcers or injuries, new or worsened	1.47%	2.29% 0.8 pts better	Numerator 1 · Denominator 68 · Adjusted rate 1.9%
Healthcare-associated infections requiring hospitalization	7.63%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 73 · Observed rate 9.59% · Lower 95% interval 4.72%
Staff COVID-19 vaccination coverage	13.21%	8.2% 5 pts better	Numerator 7 · Denominator 53
Staff flu vaccination coverage	100%	42% 58 pts better	Numerator 65 · Denominator 65
Discharge function score	25%	56.45% 31.5 pts worse	Numerator 13 · Denominator 52
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 37 · Denominator 37
Resident COVID-19 vaccinations up to date	38.89%	25.2% 13.7 pts better	Numerator 14 · Denominator 36

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.1%	95.7% 0.6 pts worse	93.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 92.6% · Q3 96.4% · Q4 95.8% · 4Q avg 95.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.5%	95.0% 1.5 pts worse	95.5% 2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5%
Percentage of long-stay residents experiencing one or more falls with major injury	4.9%	3.2% 1.7 pts worse	3.3% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.4% · Q3 3.6% · Q4 4.2% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	5.0% 5 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	3.8%	4.9% 1.1 pts better	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 4.2% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.0%	16.6% 2.4 pts worse	19.6% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q2 15.0% · Q3 20.8% · 4Q avg 19.0%
Percentage of long-stay residents who received an antipsychotic medication	7.6%	16.7% 9.1 pts better	16.7% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q3 10.0% · 4Q avg 7.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	25.7%	21.1% 4.6 pts worse	16.3% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 25.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	30.4%	17.3% 13.1 pts worse	14.9% 15.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 20.8% · 4Q avg 30.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	5.4%	2.3% 3.1 pts worse	1.0% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 8.6% · Q3 6.0% · Q4 3.5% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	5.8%	3.0% 2.8 pts worse	1.7% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 14.8% · Q3 3.6% · Q4 0.0% · 4Q avg 5.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.2%	25.5% 0.3 pts better	19.8% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 28.1% · Q3 30.3% · Q4 11.6% · 4Q avg 25.2%
Percentage of long-stay residents with pressure ulcers	3.8%	5.5% 1.7 pts better	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 3.2% · Q4 5.8% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.5%	86.8% 9.7 pts better	81.7% 14.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 97.3% · Q3 96.7% · Q4 97.0% · 4Q avg 96.5%
Percentage of short-stay residents who had an outpatient emergency department visit	24.1%	15.0% 9.1 pts worse	12.0% 12.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 22.4% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	84.2%	82.2% 2 pts better	79.7% 4.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	38.9%	22.7% 16.2 pts worse	23.9% 15 pts worse	Short Stay · 20240701-20250630 · Adjusted 38.9% · Observed 36.7% · Expected 22.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-14 · Fire 2025-05-14

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-03-20 · Fire 2024-03-20

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2023-03-08 · Fire 2023-03-08

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-14

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2025-06-06

F · Potential for more than minimal harm 2025-05-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-14

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-05-14

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-06-05

C · Minimal harm 2025-05-14

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-06-30

F · Potential for more than minimal harm 2024-03-20

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2024-04-19

F · Potential for more than minimal harm 2024-03-20

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2024-04-19

F · Potential for more than minimal harm 2024-03-20

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-04-19

F · Potential for more than minimal harm 2024-03-20

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-03-28

F · Potential for more than minimal harm 2024-03-20

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-04-19

E · Potential for more than minimal harm 2024-03-20

K321 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-04-19

E · Potential for more than minimal harm 2024-03-20

K341 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-04-10

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-14

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-05-14

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-05-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-05-14

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-05-14

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-05-14

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-05-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-11

J · Immediate jeopardy 2024-06-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-28

F · Potential for more than minimal harm 2024-03-20

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-04-12

D · Potential for more than minimal harm 2024-03-20

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-04-12

D · Potential for more than minimal harm 2023-03-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-03-31

Penalties and ownership

What sits behind the stars

$13,886 2024-06-27

Fine

Fine · fine $13,886

Fine