Edenbrook of Green Bay

Inspectors wroteBased on interview and record review, the facility did not ensure the right to make healthcare decisions was provided for 1 resident (R) (R1) of 1 sampled resident. R1 had an activated Power of Attorney for Healthcare (POAHC). R1's medical record contained multiple documents signed by a family member who was not their POAHC. The facility did not have authorization to allow someone other than R1's POAHC to make medical decisions on their behalf.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 resident (R) (R2) of 11 sampled residents received care and treatment in accordance with their plan of care. The physician was not notified when R2's blood pressure (BP) was outside the ordered parameters. The provider indicated they would have instructed staff to recheck R2's BP, notify their cardiologist, and monitor their symptoms which were not completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure assessments and daily skilled/alert charting was completed for 2 residents (R) (R7 and R12) of 13 sampled residents. R7's medical record did not contain assessments on 5/14/26 and 5/19/26 to ensure R7 was monitored and evaluated post-fall. R12 was admitted to the facility without initial nursing assessments to determine R12's required level of assistance.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of high-risk medications for 3 residents (R) (R7, R11, and R12) of 4 sampled residents. R7 was prescribed oral vancomycin (an antibiotic medication) for clostridioides difficile (C. diff) infection. R7's medical record did not indicate staff monitored R7 for adverse reactions to the high-risk medication. R11 was prescribed IV cephalexin (an antibiotic medication) for cellulitis. R11's medical record did not indicate staff monitored R11 for adverse reactions to the high-risk medication. R12 was prescribed IV ceftriaxone sodium (an antibiotic medication) for osteomyelitis and sepsis. R12's medical record did not indicate staff monitored R12 for adverse reactions to the high-risk medication.

Inspectors wroteBased on staff interview and record review, the facility did not provide timely laboratory services for 1 resident (R) (R2) of 3 sampled residents. Nurse Practitioner (NP)-E ordered a potassium lab to be drawn for R2 by 3:00 PM on 3/25/26 due to a critical potassium blood level. The lab was not drawn until 3/26/26 at approximately 9:00 AM.

Inspectors wroteBased 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.

Inspectors wroteBased 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. In addition, R2's Kardex (an abbreviated care plan used by nursing staff) did not indicate R2 was on isolation precautions and R2's medical record did not contain Clostridium Difficile as a diagnosis. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain dignity during meal time for 3 residents (R) (R22, R29, and R59) of 4 sampled residents. R22, R29, and R59 required assistance with eating. On 8/26/25, staff moved between R22, R29, and R59 (who were at different tables) while providing assistance with breakfast and stood while feeding them.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 3 residents (R) (R65, R52, and R9) of 3 sampled residents. Staff did not update the provider with a weight gain of 3 pounds or more in one day or 5 pounds or more in one week as ordered for R65, R52, and R9.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure pain medication was provided timely for 1 resident (R) (R4) of 3 sampled residents. R4 received Hospice services and had an order for as needed (PRN) morphine for pain. On either 7/8/25 or 7/20/25, R4 requested PRN pain medication. R4 did not receive the medication timely.

Inspectors wroteBased 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. The eye drops did not contain an open date. On 6/6/25, Surveyor observed LPN-D prepare and administer 5 units of Basaglar KwikPen (insulin) 100 units/milliliter (ml) to R10. The insulin pen did not contain an open date. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmacy services to ensure the accurate and safe administration of medication for 1 resident (R) (R10) of 3 residents observed during medication administration. R10 had an order for insulin aspart injection solution 100 units/milliliter (ml) inject 5 units subcutaneously before meals for hyperglycemia related to type 2 diabetes. On 6/6/25, Licensed Practical Nurse (LPN)-D incorrectly administered 5 units of Basaglar KwikPen (long-acting insulin) 100 units/ml to R10.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff followed proper infection control practices for 4 residents (R) (R9, R10, R11, and 14) of 4 sampled residents. On 6/6/25, Licensed Practical Nurse (LPN)-D did not complete hand hygiene before preparing or after administering medication to R9, R10, and R11. On 6/6/25, Certified Nursing Assistant (CNA)-E placed wash cloths in an unsanitized sink and ran water over them. CNA-E then wrung out the wash cloths, hung them over the side of the sink, and used them to complete pericare for R14.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R5) of 10 sampled residents received assistance with a request in a timely manner. On 2/26/25, R5's call light was activated at 6:46 AM. Certified Nursing Assistant (CNA)-G turned R5's call light off at 7:12 AM after R5 requested a cup of coffee. R5 was not provided coffee until R5's breakfast tray was delivered at 8:10 AM.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide the necessary care and treatment to maintain the highest practicable well being for 2 residents (R) (R7 and R10) of 10 sampled residents. Staff did not consistently complete daily weights as ordered for R7 and R10.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 2 residents (R) (R9 and R10) of 8 sampled residents. R9's care plan contained an intervention for the assistance of two staff and a full-body (Hoyer) lift for transfers. The intervention was not consistently followed. R10's care plan contained an intervention for the assistance of two staff and a sit-to-stand (EZ Stand) lift for transfers. The intervention was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility's nursing staff postings did not contain accurate data and were not retained for 18 months. This practice had the potential to affect all 68 residents in the facility. The facility did not update the daily nursing staff postings when there were schedule changes. The nursing staff postings contained numbers for staff in a full shift row despite the fact staff only worked a partial shift. In addition, the facility did not retain the postings for 18 months.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 4 residents (R) (R49, R3, R22, and R27) of 5 sampled residents. The facility did not clean continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) machines per manufacturer's instructions and the facility's policy.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure menu serving sizes were followed for therapeutic and mechanically altered diets for 5 residents (R) (R69, R12, R62, R11, and R2) of 19 sampled residents. Staff served smaller portions than the extended menu indicated for R69 who had an order for double protein and R12, R62, R11, and R2 who were prescribed mechanically altered diets.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R54) of 19 sampled residents had a self-administration of medication assessment or a physician's order to self administer medication. On 715/24, Surveyor observed medication left at R54's bedside. R54 did not have a self-administration of medication assessment or a physician's order to self-administer medication.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 resident (R) (R48) of 1 resident reviewed for smoking. R48 was known by the facility to smoke. The facility allowed R48 to carry R48's smoking materials in R48's wheelchair.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 2 residents (R) (R47 and R49) of 10 residents with indwelling catheters. R47 and R49's uncovered catheter drainage bags were observed in contact with the floor.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure medications were labeled and stored appropriately for 3 residents (R) (R21, R32, and R9) of 8 sampled residents. During observations of medication administration, Surveyor observed staff administer open and undated medications to R21 and R32. On 715/24, Surveyor observed wound care treatment solutions and acetic acid stored on R9's bedside table which was not in accordance with the facility's policy.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 residents (R) (R51 and R54) of 19 residents. R51 had wounds that required wound care and was not on enhanced barrier precautions (EBP). R54 had an indwelling catheter and was not on EBP.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure vaccinations were administered for 1 resident (R) (58) of 5 sampled residents. The facility did not administer R58 the PCV20® vaccine after R58 signed a consent form to receive the vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not permit immediate access to a resident by a representative of the protection and advocacy systems, as designated by the state, and as established under the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (42 U.S.C. 15001 et seq) for 1 Resident (R) (R2) of 5 sampled residents. The facility denied access to resident information to a representative from APS (Adult Protective Services) and a representative from the Department of Corrections (DOC) (Probation Officer).

Inspectors wroteBased 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.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition and/or treatment for 2 Residents (R) (R1 and R4) of 8 sampled residents. R1 experienced multiple episodes of syncope (fainting) as well as a change in wound treatment. The changes were not communicated to R1's activated Power of Attorney for Healthcare (POAHC). R4 experienced signs and symptoms of a urinary tract infection (UTI) on two occasions that required a change in medical treatment. In addition, R4 experienced signs and symptoms that required the need for laboratory testing and an X-ray. The changes were not communicated to R4's activated POAHC.

Inspectors wroteBased on record review and staff interview, the facility did not ensure laboratory services were provided timely for 1 Resident (R1) of 8 sampled residents. R1's primary care provider ordered a urinalysis (UA) on 1/15/24. The UA was not completed until 1/19/24.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R44) of 1 sampled resident was provided oral hygiene assistance. R44 reported staff did not offer R44 oral care which was verified during an observation on 7/26/23.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure effective pain management was provided for 1 Resident (R) (R216) of 3 sampled residents. R216 was not provided effective pain management from 7/21/23 through 7/24/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R50) of 5 sampled residents was monitored for adverse consequences of a high risk medication. R50 was prescribed Xarelto (an anticoagulant). R50 did not have a care plan that addressed Xarelto use or contained interventions to monitor for adverse consequences of the high risk medication.