Cycle 1
Health 2025-09-10 · Fire 2025-09-10
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Omro, WI
Edenbrook Omro
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
500 Grant Ave, Omro, WI
(920) 685-2755
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eden Senior Care
Operator or chain grouping
Approved since
1987-03-01
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
1.32
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
57%
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
11,785
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.06
Baseline 51.52% · Performance 51.16% · Measure score 3.06 · Achievement 3.06 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.47 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 17.5% · Lower 95% interval 7.33% |
| Discharge to community | 46.68% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 38.46% · Lower 95% interval 31.56% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 21.74% |
8.2%
13.5 pts better
|
Numerator 15 · Denominator 69 |
| Staff flu vaccination coverage | 71.21% |
42%
29.2 pts better
|
Numerator 47 · Denominator 66 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · 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 | 97.8% |
95.7%
2.1 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 95.2% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
95.0%
1.3 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · 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 · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.1% |
16.6%
7.5 pts worse
|
19.6%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q3 25.0% · 4Q avg 24.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 38.2% |
16.7%
21.5 pts worse
|
16.7%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.2% · 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 need for help with daily activities has increased | 10.7% |
17.3%
6.6 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
3.0%
1.4 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.5% · Q3 4.5% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
25.5%
3.9 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 26.7% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.5%
0.6 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.7% · Q3 6.1% · Q4 2.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
86.8%
5.2 pts worse
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 73.9% · Q3 87.3% · Q4 90.6% · 4Q avg 81.6% |
| 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 | 80.3% |
82.2%
1.9 pts worse
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-14 · Fire 2023-06-14
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-09-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-10
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 2025-10-03
F · Potential for more than minimal harm
2025-09-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-09-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-09-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-09-10
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 2025-10-03
E · Potential for more than minimal harm
2025-09-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-09-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-10-09
F · Potential for more than minimal harm
2024-07-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-24
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 2024-08-19
E · Potential for more than minimal harm
2024-07-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-24
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-08-19
F · Potential for more than minimal harm
2023-06-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-06-14
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 2023-06-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-21
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 2025-12-12
F · Potential for more than minimal harm
2025-09-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-10
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-09-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-03
E · Potential for more than minimal harm
2024-10-16
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 2024-11-15
E · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-16
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 2024-11-15
D · Potential for more than minimal harm
2024-07-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-20
D · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-20
G · Actual harm
2023-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-03-27
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-04-27
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
Mauer, Dovie
Operational/Managerial Control · Individual
Polstein, Mordechai
Operational/Managerial Control · Individual
Rice, Pamela
Operational/Managerial Control · Individual
Rice, Pamela
W-2 Managing Employee · Individual
Watson, William
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Eden Rehab Suites And Green House Homes
Oshkosh, WI
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
#2
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
#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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