Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Edenbrook Sheboygan
Sheboygan, WI · 121 certified beds · Last Life Safety survey July 8, 2026
CMS Certification Number 525568 · first certified July 1995
Ownership
Operated by EDEN SENIOR CARE · For profit - Corporation
- New ownershipOwnership changed April 24, 2025 (change of ownership)from SUNNY RIDGE OPERATIONS LLC
Position within WI
30 citations — more than 86% 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 5 citations; the earlier surveys on file averaged 8.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens August 2027 — about 9 months from now. This facility’s last Life Safety survey was July 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 519 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 about three years in Virginia. How the window is measured
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3 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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 30 citations on file is 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)
9 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 30 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- 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.
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 | 30 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 17, 2024 | 1 |
| February 28, 2024 | 14 |
| April 30, 2025 | 10 |
| July 8, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2026-07-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2026-07-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-07-08 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2026-07-08 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-04-30 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-02-28 |
| K-0500 | Meet other general requirements that are deficient. | 1 | 2024-01-17 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2025-04-30 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Miscellaneous Deficiencies 6
- Egress Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Miscellaneous Deficiencies | 6 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 8, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 13, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 13, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 13, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 13, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has plan of correction (December 31, 2026) |
April 30, 2025 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (May 30, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 30, 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 (July 29, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 14, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 30, 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 (May 30, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (May 30, 2025) |
February 28, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (March 27, 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 27, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (April 5, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 27, 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 27, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 27, 2024) |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Deficient, Provider has date of correction (March 27, 2024) |
January 17, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (February 7, 2024) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.