B+
83/100Edenbrook Omro Inspection Report, Violations & Safety Grade (Omro, Wisconsin)
500 Grant Ave, Omro, Wisconsin 54963
Phone: 9206852755
CMS Overall:4/5
Overview & Bed Count
Certified Beds
50
Avg Residents/Day
30.8
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Winnebago
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.20 | 0.98 | +0.21 |
| Total Nurse Hours per Resident per Day | 4.28 | 4.25 | +0.03 |
| CMS Staffing Rating | 3/5 | 3.7/5 | - |
| Nursing Staff Turnover | 60.7% | 46.7% | - |
Health Citation History
17 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-01 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-10-21 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-09-10 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2025-09-10 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2025-09-10 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-10-16 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2024-10-16 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-10-16 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2024-10-16 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-10-16 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-07-24 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-07-24 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2023-06-14 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2023-06-14 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-06-14 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2023-06-14 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2023-06-14 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
Fire Safety Citation History
27 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-10 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2025-09-10 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2025-09-10 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | F – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | F – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-09-10 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | F – Moderate Harm Potential |
| 2025-09-10 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-09-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-09-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | F – Moderate Harm Potential |
| 2025-09-10 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2025-09-10 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2024-07-24 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | F – Moderate Harm Potential |
| 2024-07-24 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-07-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-07-24 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-07-24 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-07-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-07-24 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-07-24 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2024-07-24 | Services Deficiencies | Have an externally vented heating system. | D – Moderate Harm Potential |
| 2023-06-14 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-06-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-06-14 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Omro area at no cost.
Find Safe, Vetted Facilities Near Omro
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.