Edenbrook Sheboygan

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was served and stored in a safe and sanitary manner. This practice had the potential to affect 59 of 60 residents residing in the facility. (One resident received all nutrition through a feeding tube.) Staff did not properly label, date, or store food in a manner to ensure food safety. Testing and documentation of parts per million (PPM) of the sanitizing solution were not accurately completed. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not follow safe food cooling protocol. Staff did not reheat food served to a resident in accordance with their policy.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 60 residents residing in the facility. Staff did not offer residents hand hygiene before a meal. R8 was on enhanced barrier precautions (EBP) due to a feeding tube. Staff flushed R8's feeding tube without donning the appropriate personal protective equipment (PPE).

Inspectors wroteBased on interview and record review, the facility did not ensure adequate supervision and assistive devices to prevent accidents were provided for 1 resident (R) (R11) of 5 sampled residents. R11 fell on 3/3/26 and 5/15/26. Post-fall assessments for the 3/3/26 fall did not start until 3/4/26. Two post-fall assessments were not completed. In addition, two post-fall assessments for the 5/15/26 fall were not completed.

Inspectors wroteBased on interview and record review, the facility did not ensure feeding assistance was provided for 2 residents (R) (R24 and R23) of 3 sampled residents. Staff did not provide feeding assistance for R24 and R23 in accordance with their plans of care. In addition, R24 and R23's Minimum Data Set (MDS) assessments and plans of care contained inconsistent information regarding their feeding requirements.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R38) of 18 sampled residents. R38 used an insulin pump to administer insulin at the bedside 3 times daily. R38 did not have a self-administration of medication assessment, an order to self-administer medication, or an order to administer insulin via pump. In addition, staff did not document the insulin administration in R38's Medication Administration Record (MAR).

Inspectors wroteBased 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. The immediate jeopardy was removed and corrected on [DATE] and is being cited at past non-compliance.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision and assistive devices to prevent accidents were provided for 4 residents (R) (R1, R2, R3, and R5) of 4 sampled residents. R1 fell on 1/10/26. R1's post-fall assessments did not start until 1/12/26. In addition, three of 8 post-fall assessments did not include an updated set of vital signs (VS). In addition, an intervention for gripper socks was not added to R1's care plan. R2 fell on [DATE], 12/2/25, and 12/10/25. Ten of 31 documented post-fall assessments did not include an updated set of VS. R3 fell twice on 11/27/25 while reaching for items. Three of 10 documented post-fall assessments did not include an updated set of VS. In addition, R3 did not have grabbers within reach on 2/4/26 in accordance with R3's care plan. R5 fell on [DATE]. [...]

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure the right to participate or designate others to participate in the care planning process for 3 residents (R) (R2, R3, and R5) of 5 sampled residents. Quarterly care conferences were not offered for R2, R3, and R5 in the last year.

Inspectors wroteBased 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. An investigation indicated R1 exited through a second-floor stairwell door with a functioning alarm. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe manner. This practice had the potential to affect all 65 residents residing in the facility. Food temperatures logs were incomplete for items served to residents. Beverage temperatures were greater than 41 degrees Fahrenheit (F) prior to serving residents on the third floor.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not notify a Guardian of a change in condition or a need to alter treatment for 1 resident (R) (R1) of 1 sampled resident. R1 eloped from the facility on 11/27/25. R1's Guardian was not notified of the elopement until 12/1/25. R1 fell on [DATE] at 11:20 AM and 7:28 PM. R1's Guardian was not notified of the second fall.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents was assessed following a fall with injury prior to being transferred from the floor into bed. R1 sustained a fall with injury on 12/1/25 at 11:20 AM. An X-ray was ordered and pending review. R1 sustained a second fall with reported pain on 12/1/25 at 7:28 PM. R1 was transferred from the floor into bed with the use of Hoyer slings without a physical assessment to ensure R1 was medically safe to be transferred.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents was free from a chemical restraint not required to treat the resident's medical symptoms. The facility did not implement non-pharmacological interventions prior to administering antipsychotic medication to decrease R2's behaviors. Findings Include:The facility's Policy & Procedure Psychotropic Medication, dated 5/1/25, indicates: Purpose: To provide guidance for the psychopharmacologic drug treatment for a resident with a specific condition, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record .1. An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing identified behavior. 2. [...]

Inspectors wroteBased on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure 4 residents (R) (R1, R2, R7, and R10) of 5 sampled residents who required assistance for activities of daily living (ADLs) were provided care in a timely manner. R1 expressed concerns about long call light response times. On 7/9/25, R1 indicated R1 was incontinent and requested to be changed but was told R1 would have to wait until after lunch. R2 and R2's Guardian expressed concerns about call light response times and that R2 was not changed timely. R7 expressed concerns about long call light response times. R7 filed a grievance related to the concerns but continued to experience long call light response times. R10 expressed concerns about long call light response times which resulted in R10 having to wait for R10's needs to be met.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was prepared and served in a safe and sanitary manner. This practice had the potential to affect 58 of 59 residents residing in the facility. One resident received nutrition via tube feeding. The facility's dishwasher did not reach the minimum wash temperature to prevent the spread of foodborne illness. Staff did not complete appropriate hand hygiene during two meal service observations.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R47) of 2 sampled residents with a Guardian had protective placement in the facility. R47 had a legal Guardian at the time of admission on [DATE]. The facility did not have evidence of court-ordered protective placement (required when nursing home residency exceeds 90 days).

Inspectors wroteBased on staff interview and record review, the facility did not notify the State Long-Term Care Ombudsman when 2 residents (R) (R17 and R46) of 6 sampled residents were transferred to the hospital. R17 was transferred to the hospital on [DATE]. The facility did not notify the Ombudsman of R17's hospital transfer. R46 was transferred to the Emergency Department (ED) on 3/19/25 and 3/28/25. The facility did not notify the Ombudsman of R46's ED transfers.

Inspectors wrote2. On 4/28/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, depression, and psychotic disorder. R13's MDS assessment, dated 2/27/25, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R13 had severely impaired cognition. R13's PASRR Level I Screen was completed on 11/19/24 by the facility. The Level I Screen indicated R13 did not have a major mental disorder and did not receive psychotropic medication to treat symptoms or behaviors of a major mental disorder. As a result of the Level I Screen, a Level II Screen was not completed. R13's physician orders indicated R13 was prescribed the following medications with contributing diagnoses: [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision and assistance devices were provided for 1 resident (R) (R33) of 3 sampled residents. R33 had 7 falls in the past 6 months. R33's plan of care indicated R33 required assistance with ambulation and transfers to the bathroom and bed, however, staff allowed R33 to ambulate and transfer independently in R33's room.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R43 and R107) of 7 sampled residents. R43 was on droplet precautions. On 4/29/25, Maintenance/Transport Employee (MTE)-L was observed programming a remote control in R43's room without a mask, gloves, or eye protection. R107 was on enhanced barrier precautions (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident cares to reduce the spread of multidrug-resistant organisms). On 4/28/25, Assistant Director of Nursing (ADON)-C administered R107's intravenous medication without wearing a gown.

Inspectors wroteBased 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 [DATE] 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. Pressure-relieving interventions (heel boots) for R1's feet were not implemented or added to R1's plan of care until 1/23/25. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified when 1 resident (R) (R3) of 2 sampled residents was sent to the hospital. On 9/25/24, R3's Power of Attorney for Healthcare (POAHC) contacted Emergency Medical Services (EMS) to have R3 sent to the emergency room (ER). Staff did not notify R3's physician and R3 did not return to the facility.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R1 and R2) of 13 sampled residents. R1 and R2 had resident-to-resident altercations on 10/11/24 and 10/13/24. The resident-to-resident altercations were not thoroughly investigated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure oral care was consistently completed for 3 residents (R) (R3, R5, and R6) of 7 sampled residents. Oral care was not consistently documented as completed, unavailable, or refused in R3's medical record. Oral care was not consistently documented as completed, unavailable, or refused in R5's medical record. Oral care was not consistently documented as completed, unavailable, or refused in R6's medical record.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure appropriate catheter care and services were provided for 2 residents (R) (R9 and R3) of 7 sampled residents. On 11/25/24, R9's catheter tubing and uncovered drainage bag were observed on the floor. R3 had a Foley catheter upon admission. R3 did not have a physician order for catheter care or documentation related to catheter care and output.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide a working call light for 1 resident (R) (R9) of 6 sampled residents. On 11/25/24, R9's call light was not in working condition.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure a clean, comfortable, or home-like environment for 1 Resident (R) (R4) of 10 sampled residents. R4's wheelchair was visibly dirty. The facility did not have documentation that indicated R4's wheelchair was routinely cleaned.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care and treatment were provided in a timely manner for 1 Resident (R) (R2) of 10 sampled residents. Staff did not notify R2's physician timely of a change in condition on 6/4/24. In addition, staff did not document completed assessments for R2's change in condition on 6/4/24.

Inspectors wroteBased 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. R1 crawled out an open second story window without a screen, walked along a narrow ledge that was approximately 18 inches wide to a roof landing, and stood on the far ledge of the landing with R1's arms outstretched. R1 stated that R1 wanted to die. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 10 Residents (R) (R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12) of 10 residents in 2 of 2 medications carts were stored, labeled or dated appropriately. The facility also did not ensure 1 of 1 refrigerator in the medication storage room that contained insulin vials maintained a temperature of 41 degrees Fahrenheit (F) or lower. In addition, the facility did not ensure 2 of 2 medication carts were locked when unattended. Medication carts contained unopened insulin vials that should remain refrigerated until opened. The carts also contained open, undated, and expired medications. Refrigerator temperature log sheets for the second floor medication room refrigerator contained temperatures greater than 41 degrees F. The log sheets indicated the temperature should be 41 degrees F or lower. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent and/or promote healing for 2 Residents (R) (R32 and R18) of 4 residents reviewed for pressure injuries. R32 had an area of moisture-associated skin damage (MASD) that was identified on 12/18/23. R32 did not have a documented treatment for the area until 1/13/24 and did not see a wound doctor until 1/24/24. The area deteriorated to an unstageable pressure injury that became infected. The facility did not contact R32's physician when the wound deteriorated and R32's care plan was not updated until 1/24/24. In addition, on 2/28/24, Surveyor observed R32 sitting on a sling in R32's wheelchair. R18 was admitted to the facility with pressure injuries on the left buttock and left heel. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure grievance forms and investigations were completed in a timely manner for 2 Residents (R) (R168 and R170) of 23 sampled residents. R168 informed staff of missing laundry items. A grievance form was not completed and the grievance was not investigated in a timely manner. R170 informed staff of a missing blanket. A grievance form was not completed and the grievance was not investigated in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of abuse was thoroughly investigated for 2 Residents (R) (R55 and R366) of 23 sampled residents. A facility-reported incident (FRI) indicated R55 was observed holding R366's face and kissing R366's lips on 2/4/24. The FRI was not thoroughly investigated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure pharmacy recommendations were acted on by a physician for 3 Residents (R) (R2, R14 and R52) of 5 residents reviewed for unnecessary medications. The facility did not follow up on five pharmacy recommendations for R2 that were not acknowledged by R2's physician. The facility did not follow up on five pharmacy recommendations for R14 that were not acknowledged by R14's physician. The facility did not follow up on six pharmacy recommendations for R52 that were not acknowledged by R52's physician.