Edenbrook of Oshkosh

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Nov 25, 2025

  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 72 residents residing in the facility. Food was not sealed, labeled, or dated appropriately.Food temperatures were not consistently documented prior to meal service.Kitchen cookware was not stored properly. In addition, kitchen equipment and the floor were not in clean condition. The rehab unit refrigerator was not in clean condition and contained undated and expired resident food.Staff touched ready-to-eat food with soiled gloves during lunch service.Findings include:On 11/25/25 at 8:39 AM, Surveyor completed a kitchen tour with Dietary Manager (DM)-C who indicated the facility follows the Wisconsin… […]

• No harm, potential for more than minimal, widespreadF803Feb 6, 2024

  Based on observation, staff interview, and record review, the facility did not ensure menu serving sizes were followed for protein, vegetable, and starch servings for mechanically altered (minced and moist) and regular consistency diets. This practice had the potential to affect 67 of 70 residents residing in the facility. During the lunch meal on 2/4/24, the facility served smaller serving portions than the lunch menu and diet tray cards indicated for 6 residents who received mechanically altered diets and 61 residents who received regular consistency diets. Findings include: During a continuous kitchen observation of lunch service beginning at 11:14 AM on 2/4/24, Surveyor noted diet tray cards for the lunch meal indicated: One pork rib, 4 oz. (ounce) serving of green beans, 4 oz. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2022

  Based on observation, staff interviews, and record review, the facility did not ensure food was prepared and served under sanitary conditions. The practices had the potential to affect all 72 residents. Staff documented hot water sanitization warewashing machine (dishwasher) operated below minimum rinse temperature of 180 degrees Fahrenheit (F)/82 degrees Celsius (C) on 15 dates between 12/27/21 and 2/14/22. Staff did not monitor dishwashing machine internal surface temperatures at least weekly. Staff did not have a dating system in place for open condiments and had other open, undated foods and beverages in walk-in refrigerator. Dietary Cook (DC)-R, Maintenance Supervisor (MS)-O, and Maintenance Assistant (MA)-P did not wear hair restraints in the kitchen. […]

• No harm, potential for more than minimal, patternF686May 5, 2026

  Based on observation, staff and resident interview, and record review, the facility did not ensure 4 residents (R) (R1, R18, R53, and R41) of 4 sampled residents received the necessary care and services to prevent pressuries injuries from developing or worsening and/or promote healing.R1 was admitted to the facility with stage 3 and 4 pressure injuries. During wound care, Registered Nurse (RN)-H applied ointment to the wound bed of R1's stage 4 left buttock pressure injury with a soiled glove.R18's specialty air mattress was not turned on during an observation on 5/3/26. In addition, R18 did not have an order for the mattress and the setting wasn't indicated in R18's medical record. […]

• No harm, potential for more than minimal, patternF809Nov 25, 2025

  Based on observation, staff and resident interview, and record review, the facility did not ensure meals were served timely. This practice had the potential to affect more than 4 of the 72 residents residing in the facility.On 11/25/25, the lunch meal was served late.Findings include:The posted meal times on the meal service line for lunch were: Hall 4: 11:30 AM - start by 11:10 AM; Hall 2: 11:40 AM - start by 11:30 AM; Hall 1: 11:50 AM - start by 11:35 AM; Dining Room: 12:05 PM - start by 11:55 AM.On 11/25/25 at 11:00, Surveyor entered the kitchen to watch lunch service and noted the Hall 4 meal service started at 11:45 AM. The Hall 4 lunch service cart was completed and sent to the unit at 12:00 PM. […]