Edenbrook of Fond Du Lac

In the surveyor’s words

From the most serious findings on record at Edenbrook of Fond Du Lac, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 11, 2025

  Based on staff and resident interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R28) of 2 residents reviewed for elopement.R28's care plan indicated R28 was at risk for wandering/elopement after an episode of confusion while outside on 10/7/24. A WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was placed on R28's left ankle. On 5/20/25 at 3:36 AM, the local police department notified the facility that R28 was found two and a half blocks from the facility. Staff were unaware R28 had left the facility. An assessment indicated R28 had no injuries. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2024

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 47 residents residing in the facility. Staff did not complete hand hygiene prior to handling clean dishes. Staff did not maintain cooling logs for leftover food. Findings include: On 5/13/24 at 8:57 AM, Surveyor began an initial kitchen tour with Dietary Manager (DM)-C who indicated the facility followed the Food and Drug Administration (FDA) 2022 Food Code. 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 19, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner which had the potential to affect all 56 residents residing in the facility. Uncovered desserts and drinks were transported from the hallway into resident rooms and the dining room. The dishwasher rinse temperature was above the required threshold of 194 degrees Fahrenheit (F). Juice cartridges in the juice machine were undated. A juice machine, microwave, and can opener were not in clean condition. A box with twelve containers of Quaker Oats Oatmeal was stored on the floor in the dry storage room. […]

• No harm, potential for more than minimal, patternF757May 15, 2024

  Based on staff interview and record review, the facility did not ensure potential adverse reactions to high-risk medications were monitored for 4 residents (R) (R22, R46, R11, and R30) of 5 residents reviewed for unnecessary medications. Staff did not monitor R22, R46, and R11 for potential side effects or adverse reactions to antibiotic medication. Staff did not monitor R22, R46, and R30 for potential side effects or adverse reactions to anticonvulsant medication. Findings include: The facility's Seizure Assessment and Management policy, revised 3/13/24, indicates: The nurse will monitor for complications related to antiepileptic medications; for example, dizziness, ataxia, somnolence, headache, diplopia, blurred vision, nausea, vomiting, and rash. […]

• No harm, potential for more than minimal, patternF880May 15, 2024

  Based on observation, staff interview, and record review, the facility did not ensure staff performed hand hygiene before administering medication and providing assistance for 4 residents (R) (R30, R24, R2, and R43) of 6 residents observed during medication administration. Licensed Practical Nurse (LPN)-J did not consistently perform hand hygiene during medication administration and while providing assistance to residents. Findings include: The facility's Administering Medications Policy and Procedure, revised on 1/22/24, indicates: .15. Adherence to established facility infection control procedures shall be followed during the administration of medications: Hand hygiene per policy shall be required between residents. […]