Cycle 1
Health 2025-03-26 · Fire 2025-03-26
14 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Oshkosh, WI
Edenbrook Of Oshkosh
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
1850 Bowen St, Oshkosh, WI
(920) 233-4011
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eden Senior Care
Operator or chain grouping
Approved since
1985-10-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
0.72
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.16
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,090
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.47
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
5.36
Baseline 19.21% · Performance 18.95% · Measure score 5.36 · Achievement 5.36 · Improvement 0.71
Healthcare-associated infections
0.94
Baseline 6.15% · Performance 7.56% · Measure score 0.94 · Achievement 0.94 · Improvement 0
Total nurse turnover
1.46
Baseline 54.35% · Performance 57.69% · Measure score 1.46 · Achievement 1.46 · Improvement 0
Adjusted total nurse staffing
0.83
Baseline 3.28 hours · Performance 3.31 hours · Measure score 0.83 · Achievement 0.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.57% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 22.54% · Lower 95% interval 8.64% |
| Discharge to community | 43.83% |
50.57%
6.7 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 35.09% · Lower 95% interval 33.08% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 9 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 34 · Adjusted rate 2.54% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 11.36% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 25.51% |
8.2%
17.3 pts better
|
Numerator 25 · Denominator 98 |
| Staff flu vaccination coverage | 31.43% |
42%
10.6 pts worse
|
Numerator 33 · Denominator 105 |
| Discharge function score | 59.09% |
56.45%
2.6 pts better
|
Numerator 13 · Denominator 22 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
95.7%
5.8 pts worse
|
93.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 84.5% · Q3 94.4% · Q4 96.1% · 4Q avg 89.9% |
| 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 | 2.8% |
3.2%
0.4 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.7% · Q3 3.7% · Q4 2.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
5.0%
2.5 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 3.9% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
4.9%
2.9 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.9% · Q3 0.0% · Q4 2.1% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.6% |
16.6%
5 pts worse
|
19.6%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 22.6% · Q3 26.5% · Q4 19.1% · 4Q avg 21.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
16.7%
0.5 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.2% · Q3 18.2% · Q4 11.8% · 4Q avg 16.2% · 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 | 21.3% |
21.1%
0.2 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 28.8% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
17.3%
8.7 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 12.0% · Q3 4.5% · Q4 6.8% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
2.3%
1.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
3.0%
2.5 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 7.5% · Q4 11.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.1% |
25.5%
6.6 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.1% · Q2 27.9% · Q3 34.3% · Q4 20.5% · 4Q avg 32.1% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.5%
1 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.3% · Q3 4.7% · Q4 4.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.4% |
86.8%
16.4 pts worse
|
81.7%
11.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.7% · Q2 70.1% · Q3 67.0% · Q4 70.4% · 4Q avg 70.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
15.0%
0.4 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 14.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.2% |
82.2%
1 pts worse
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.8% |
22.7%
8.9 pts better
|
23.9%
10.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 11.1% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-06 · Fire 2024-02-06
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
23 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-26
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-03-26
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-26
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-26
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 2025-04-26
F · Potential for more than minimal harm
2025-03-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-03-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-26
K222 · Egress Deficiencies
Fire Safety
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 2025-04-26
E · Potential for more than minimal harm
2025-03-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-26
E · Potential for more than minimal harm
2025-03-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
D · Potential for more than minimal harm
2025-03-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-26
C · Minimal harm
2025-03-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-26
F · Potential for more than minimal harm
2024-02-06
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K222 · Egress Deficiencies
Fire Safety
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 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-06
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 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-06
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
D · Potential for more than minimal harm
2024-02-06
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-06
C · Minimal harm
2024-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-06
F · Potential for more than minimal harm
2023-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-23
F · Potential for more than minimal harm
2023-01-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-25
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-02-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-25
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 2025-12-23
E · Potential for more than minimal harm
2025-11-25
F809 · Nutrition and Dietary Deficiencies
Health
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 2025-12-23
D · Potential for more than minimal harm
2025-11-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-07-29
F690 · Quality of Life and Care Deficiencies
Health
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 2025-08-16
D · Potential for more than minimal harm
2025-07-29
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-03-26
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 2025-04-26
E · Potential for more than minimal harm
2025-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F559 · Resident Rights Deficiencies
Health
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 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F584 · Resident Rights Deficiencies
Health
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 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F688 · Quality of Life and Care Deficiencies
Health
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 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-26
E · Potential for more than minimal harm
2024-08-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F761 · Pharmacy Service Deficiencies
Health
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-20
F · Potential for more than minimal harm
2024-02-06
F803 · Nutrition and Dietary Deficiencies
Health
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 2024-03-06
E · Potential for more than minimal harm
2024-02-06
F584 · Resident Rights Deficiencies
Health
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 2024-03-06
E · Potential for more than minimal harm
2024-02-06
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 2024-03-06
D · Potential for more than minimal harm
2024-02-06
F690 · Quality of Life and Care Deficiencies
Health
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 2024-03-06
D · Potential for more than minimal harm
2024-02-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-01-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-23
Penalties and ownership
What sits behind the stars
Ownership
Stesel, Maxim
5% Or Greater Direct Ownership Interest · Individual
Polstein, Mordechai
5% Or Greater Direct Ownership Interest · Individual
Feinstein, Dan
5% Or Greater Direct Ownership Interest · Individual
Lifsics, Channie
5% Or Greater Direct Ownership Interest · Individual
Mauer, Dovie
5% Or Greater Direct Ownership Interest · Individual
Pukshansky, Rostislav
5% Or Greater Direct Ownership Interest · Individual
Lifsics, Channie
Operational/Managerial Control · Individual
Mauer, Dovie
Operational/Managerial Control · Individual
Polstein, Mordechai
Corporate Officer · Individual
Rice, Pamela
Operational/Managerial Control · Individual
Wendling, Carrie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Evergreen Health Center
Oshkosh, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Park View Health Center
Oshkosh, WI
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Bethel Home
Oshkosh, WI
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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