Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Edenbrook of Oshkosh
Oshkosh, WI · 110 certified beds · Last Life Safety survey May 5, 2026
CMS Certification Number 525299 · first certified October 1985
Ownership
Operated by EDEN SENIOR CARE · For profit - Limited Liability company
- Ownership changed September 1, 2017 (change of ownership)from SIMON OSHKOSH PROPERTIES LLC
Position within WI
46 citations — more than 99% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 21. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 9 months from now. This facility’s last Life Safety survey was May 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Edenbrook of Oshkosh
One email when it happens. No account; stop it any time with one click.
6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
7 of the 46 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 46 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 46 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 6, 2024 | 23 |
| March 26, 2025 | 19 |
| May 5, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2026-05-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-05-05 |
| K-0241 | Have correct number of accessible exits for each story. | 3 | 2026-05-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-03-26 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2025-03-26 |
| K-0222 | 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. | 2 | 2025-03-26 |
| K-0711 | Provide a written emergency evacuation plan. | 2 | 2025-03-26 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-03-26 |
What the citations cover
- Smoke Deficiencies 15
- Egress Deficiencies 9
- Emergency Preparedness Deficiencies 7
- Miscellaneous Deficiencies 6
- Other 9
| Category | Citations |
|---|---|
| Smoke Deficiencies | 15 |
| Egress Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 7 |
| Miscellaneous Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 4 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 5, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has no plan of correction |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 23, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 5, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 5, 2026) |
March 26, 2025 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 26, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (April 26, 2025) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (May 23, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0222 | 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. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0241 | Have correct number of accessible exits for each story. | Waiver has been granted |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (May 21, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 26, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 26, 2025) |
February 6, 2024 — 23 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (March 6, 2024) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (March 6, 2024) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0241 | Have correct number of accessible exits for each story. | Waiver has been granted |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 6, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.