Edenbrook Sheboygan

In the surveyor’s words

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

• Immediate jeopardy, patternF689Sep 10, 2021

  Based on observation, record review and staff interview, the facility did not closely supervise Resident 1 (R1) and ensure that 25 of 25 female residents on the unit and one male resident - Residents (R) (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27) - were free from potential sexually aggressive behavior. R1 had a history of sexually aggressive behavior. R1 was placed on fifteen minute checks following multiple incidents in which R1 was observed in a female resident's room or with a female resident in R1's room. […]

• Immediate jeopardy, isolatedF678Jul 1, 2026

  Based on interview and record review, facility staff failed to provide basic life support to a resident in accordance with physician orders and an advance directive for 1 resident (R) (R2) of 6 sampled residents.R2 was enrolled in Hospice services and was discovered pulseless and nonbreathing on [DATE]. At the time of the incident, R2 was a full code. Staff failed to check R2's code status, provide cardiopulmonary resuscitation (CPR) and basic life support, or call 911. The facility's failure to provide CPR/basic life support and call 911 for a full code status resident created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 10:30 AM. […]

• Immediate jeopardy, isolatedF689Dec 17, 2025

  Based on staff and resident interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 3 residents reviewed for elopement.R1's care plan upon admission on [DATE] indicated R1 was at risk for wandering/elopement. A WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was placed on R1's right ankle. On 11/27/25, R1 attempted to exit the unit multiple times and was redirected by staff. The facility did not implement increased supervision for R1. On 11/27/25 at 5:15 PM, the police department notified the facility that R1 was found 0.6 miles from the facility in a hospital parking lot. Staff were unaware R1 had left the facility. […]

• Immediate jeopardy, isolatedF686Feb 26, 2025

  Based on observation, staff interview, and record review, the facility did not provide the appropriate care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R1) of 5 sampled residents. On 12/19/24, R1 developed what was initially classified as an arterial wound on the left foot (hallux) by former Assistant Director of Nursing (ADON)-C, who is not wound care certified. Pressure relieving interventions for R1's feet were not implemented, and the wound was not formally assessed until 1/2/25. R1 was hospitalized from 1/11/25 to 1/13/25 for pneumonia and a urinary tract infection (UTI). On 1/13/25 at the hospital, R1's left foot wound was classified as an unstageable deep tissue injury. […]

• Immediate jeopardy, isolatedF689Jul 11, 2024

  Based on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 Resident (R) (R1) of 3 residents reviewed for suicidal ideation. On 6/12/24, R1 went to the Emergency Department (ED) for suicidal ideation. An ED note instructed the facility to continue 1:1 supervision for R1, however, R1 returned to the facility without adequate supervision in place and no documented 1:1 supervision. On 6/13/24 at approximately 6:30 AM, R1 ran into the dining room and sat down near Certified Nursing Assistant (CNA)-G who left the dining room a short time later to assist other residents. […]