Edenbrook of Wisconsin Rapids

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF677May 20, 2026

  Based on observation, staff and resident interview, and record review, the facility did not ensure assistance for activities of daily living (ADLs) was provided in a timely and consistent manner for 4 residents (R30, R13, R1, and R38) of 5 sampled residents. R30's call light was shut off prior to staff completing R30's request. Staff did not return in a timely manner to complete cares for R30. R1 stated staff typically take 30 minutes to respond to R1's call light. R13's call light was activated for 14 to 24 minutes before staff provided care. R1 (who lived across the hall) was interviewed and stated R13's call light was previously on for 60 minutes. R38 stated it can take 30 minutes for staff to respond to a call light. […]

• No harm, potential for more than minimal, patternF761Jul 25, 2025

  Based on observation, staff interview, and record review, the facility did not ensure a medication cart was locked when unattended and that medications were stored appropriately. This practice had the potential to affect more than 4 of the 51 residents residing in the facility. On 7/25/25, staff left a medication cart unlocked and unattended on multiple occasions. In addition, staff left medications on top of an unattended medication cart. Findings include:The facility's Administering Medications policy, revised 1/22/24, indicates: .Medication will remain secured in a locked cabinet/cart unless in direct view of the individual administering the medication. 1.On 7/25/25 at 8:28 AM, Surveyor observed Licensed Practical Nurse (LPN)-C prepare medication. […]

• No harm, potential for more than minimal, patternF559Mar 14, 2023

  Based on interview and record review, the facility did not notify the residents of a room change in writing nor notify them of the reason they were being moved for 4 of 4 residents reviewed, Resident (R) R5, R6, R7, and R8. The facility did not explain to residents who were being moved, why they were being moved, nor did they provide written notice. R5 was moved from room [ROOM NUMBER] to 610 on 3/9/23. R5 had a BIMS score of 14 indicating they were cognitively intact. R5 was responsible for self. R6 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 3/13/23. R6 had a BIMS score of 15 indicating they were cognitively intact. R6 was responsible for self. R7 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 3/9/23. […]

• No harm, potential for more than minimal, isolatedF610May 20, 2026

  Based on staff interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R68) of 1 sampled resident.Housekeeping Supervisor (HS)-E used R68's credit card to pay $1501.97 of personal bills after R68 used HS-E's phone to make purchases. The facility did not thoroughly investigate the allegation of misappropriation.Findings include:The facility's Vulnerable Adult Abuse and Neglect Prevention policy, revised 3/25/25, indicates: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. […]

• No harm, potential for more than minimal, isolatedF684May 20, 2026

  Based on observation, staff and resident interview, and record review, the facility did not provide wound care as ordered for 1 resident (R) (R4) of 1 sampled resident. R4 developed a skin tear over a recently healed left posterior thigh wound. Physician orders were not transcribed in R4's medical record to continue treatment to protect the wound. R4's medical record did not indicate the wound was treated or covered as ordered between 5/8/26 and 5/15/26. Findings include: Between 5/19/26 and 5/20/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including chronic venous hypertension with ulcer and inflammation of left lower extremity and peripheral vascular disease (PVD). […]