Edenbrook of Green Bay

In the surveyor’s words

From the most serious findings on record at Edenbrook of Green Bay, in the surveyor’s own words.

• Actual harm, isolatedF684Feb 27, 2024

  Based on staff interview and record review, the facility did not ensure the provision of care and treatment in accordance with professional standards of practice for 2 Residents (R) (R7 and R6) of 8 sampled residents. The facility did not follow their policy or clarify a physician's order related to blood sugar parameters for R7. As a result, R7 was sent to the emergency room (ER) for treatment of hypoglycemia (low blood sugar) on 11/26/23. The facility did not ensure physician orders were followed for R6's PICC (peripherally inserted central catheter) line. […]

• No harm, potential for more than minimal, widespreadF801Aug 27, 2025

  Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This practice had the potential to affect all 70 residents residing in the facility. Findings include:On 8/26/25, Surveyor requested to review Dietary Manager (DM)-R's certification. On 8/26/25 at approximately 1:00 PM, Surveyor received paperwork from Nursing Home Administrator (NHA)-A that included a screenshot of test results for DM-R. […]

• No harm, potential for more than minimal, widespreadF812Jul 26, 2023

  Based on observation, staff interview and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 64 residents residing in the facility. Food items intended for resident consumption were without required labels and dates and some were past the manufacturer's use-by date. Nourishment room refrigerator temperature logs were incomplete. The main kitchen and nourishment room refrigerators were not clean. Findings include: Food Labeling: The Wisconsin Food Code indicates at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. […]

• No harm, potential for more than minimal, patternF880Aug 27, 2025

  Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R2, R3, and R59) of 11 sampled residents.R2 was on isolation precautions for Clostridium Difficile (C. diff). During observations of care, staff did not don the appropriate personal protective equipment (PPE) and complete hand hygiene prior to entering and exiting R2's room and did not dispose of soiled linens in accordance with the facility's policy. […]

• No harm, potential for more than minimal, patternF761Jun 6, 2025

  Based on observation, staff interview, and record review, the facility did not ensure medication was dated when opened and stored appropriately for 2 residents (R) (R9 and R10) of 3 residents observed during medication administration. In addition, staff left a medication cart unlocked and unattended and R11's Medication Administration Record (MAR) exposed during medication administration. This practice had the potential to affect more than 4 of the 74 residents residing in the facility. On 6/6/25, Surveyor observed Licensed Practical Nurse (LPN)-D prepare and administer timolol maleate ophthalmic solution 0.5 % eye drops to R9. […]