Edenbrook Of Oshkosh

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, and record review, the facility did not provide meals according to prescribed diets for 3 residents (R) (Resident R9, Resident R10, and Resident R11) of 3 sampled residents. Resident R9, Resident R10, and Resident R11 had orders for a consistent carbohydrate diet. On 11/25/25, residents on consistent carbohydrate diets were supposed to receive a half slice of garlic toast. Resident R9, Resident R10, and Resident R11 received a full slice of garlic toast.Findings include:The facility's Diet and Diet Orders policy, revised 12/11/23, indicates: .11. Residents

on therapeutic or mechanically-altered diets will not receive food or fluids outside the diet order unless approved by the attending physician in conjunction with the dietitian, nursing, and/or therapy. On 11/25/25, Surveyor reviewed Resident R9's medical record. Resident R9 had a diagnosis of type 2 diabetes and was prescribed a consistent carbohydrate (diabetic) diet.On 11/25/25, Surveyor reviewed Resident R10's medical record. Resident R10 had a diagnosis of type 2 diabetes and was prescribed a consistent carbohydrate with no added salt diet.On 11/25/25, Surveyor reviewed Resident R11's medical record. Resident R11 had a diagnosis of type 2 diabetes and was prescribed a consistent carbohydrate (diabetic) diet.On 11/25/25 at 11:00 AM, Surveyor observed food preparation and lunch service. The lunch menu indicated residents on consistent carbohydrate diets should receive 1 each manicotti with meat sauce; 4 ounces of asparagus cuts, a half slice of garlic toast, 4 ounces of canned fruit, and 8 ounces of milk. During meal service, Surveyor observed [NAME] (CK)-D put a full slice of garlic toast on Resident R9, Resident R10, and Resident R11's meal trays. Surveyor observed Resident R9, Resident R10, and Resident R11's tray cards that CK-D had reference to which indicated Resident R9, Resident R10, and Resident R11 should receive a half slice of garlic toast. On 11/25/25 at 12:02 PM, Surveyor interviewed CK-D who did not notice the tray cards indicated the residents should receive a half slice of garlic toast. On 11/25/25 at 2:30 PM, Surveyor interviewed Dietary Manager (DM)-C who confirmed residents' diet orders should be followed.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Edenbrook of Oshkosh

1850 Bowen St Oshkosh, WI 54901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

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. On 11/25/25 at 12:00 PM, Surveyor heard Dietary Manager (DM)-C tell staff to move along because meal service was late. On 11/25/25 at 12:07 PM, Surveyor noted the Hall 2 meal service started but should have started at 11:40 AM.

Surveyor followed the Hall 2 cart to the unit which was completed and sent to the unit at 12:30 PM.On 11/25/25 at 12:43 PM, Surveyor observed Certified Nursing Assistants (CNAs) start delivering meal trays

on Hall 2.On 11/25/25 at 1:16 PM, the last meal tray was delivered on Hall 2.On 11/25/25 at 12:40 PM, Surveyor interviewed Resident R7 (whose Minimum Data Set (MDS) assessment, dated 11/20/25, indicated Resident R7 had intact cognition). Resident R7 indicated meal trays should have been served by then but were consistently late. On 11/25/25 at 1:03 PM, Surveyor interviewed CNA-F who confirmed meal trays are frequently served late. On 11/25/25 at 2:30 PM, Surveyor interviewed DM-C who was aware meals were frequently served late. DM-C indicated DM-C was recently asked to work full-time at the facility to help with issues in the kitchen. DM-C had worked between 2 facilities for the previous 3 weeks. DM-C indicated DM-C would address the timeliness of meals.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Edenbrook of Oshkosh

1850 Bowen St Oshkosh, WI 54901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. On 11/25/25 at 11:00 AM, Surveyor observed CK-D prepare and serve lunch. The menu included manicotti with sauce, garlic toast, and asparagus pieces. Alternative meals were a beef patty and chicken.

Surveyor noted the following:~ CK-D changed gloves multiple times during meal service without washing hands.~ On 3 occasions, CK-D pulled CK-D's face mask down with a gloved hand and then continued serving food. CK-D touched ready-to-eat food by cutting and putting garlic toast on plates.On 11/25/25 at 11:25 AM, Surveyor observed CK-D pick up cooked chicken with a gloved hand that had touched multiple areas in the kitchen, including utensils, containers, and meal tickets. CK-D put the chicken in a blender to grind. CK-D then removed the top of the blender and touched the ground chicken with a gloved hand. CK-D tore a piece of chicken with gloved hands and placed the smaller pieces back in the blender. When the chicken was ground to the correct consistency, CK-D used the same gloved hand to guide the ground chicken into a serving dish. On 11/25/25 at 12:02 PM, Surveyor interviewed CK-D who confirmed the above

observations. On 11/25/25 at 2:30 PM, Surveyor informed DM-C of Surveyor's observations during meal service. DM-C indicated DM-C observed some of the same things and would work on training staff.

Event ID:

Facility ID:

If continuation sheet