Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Appleton Area Health during CMS and state inspections, most recent first.
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident in a wheelchair self-propelled through a dining room exit door to the outside without staff supervision, with the wander guard alarm not activating. Video showed the resident exiting, remaining outside on facility property, and staff joining the resident several minutes later before assisting the resident back inside. The incident was documented as an elopement, and staff spent time calming and redirecting the resident. The DON reported the event to the SA several hours after it occurred, explaining she believed a 24-hour timeframe applied because there was no harm. Facility policy, however, required alleged neglect to be reported immediately, but not later than two hours, when the events involved abuse or serious bodily injury, and within 24 hours otherwise.
A resident with dementia, moderate cognitive impairment, and a history of wandering and exit-seeking was identified as an elopement risk and used a wander alarm daily, but the care plan lacked complete, specific elopement and safety interventions. Despite documented behaviors such as packing a suitcase to go home and being difficult to redirect, only general distraction strategies were listed, and no additional targeted measures were added. On one occasion, the resident became agitated, packed belongings, opened a door, and went outside into the snow before being redirected, and the wander guard did not alarm as expected. The medical record did not show that redirection, reorientation, or increased supervision were implemented in response to clear elopement behaviors, and IDT members later acknowledged the care plan was incomplete and not sufficiently personalized.
A resident with dementia, moderate cognitive impairment, and a known history of exit-seeking and packing belongings to go home was care planned as an elopement risk with a wander guard alarm and diversional and supervisory interventions. On one occasion, the resident became agitated, self-propelled a wheelchair to a dining room exit, opened the door, and went outside while a staff member in the area was occupied with another resident. The wander guard alarm did not sound because the pendant was attached under the wheelchair seat on a metal piece instead of being worn on the wrist or ankle as required by the manufacturer, and staff, including the RN responsible for assessments and the DON, had not reviewed or followed the manufacturer’s placement guidelines, resulting in the device not functioning as intended when the resident left the building.
A resident with dementia, behavioral disturbances, and elopement risk did not receive individualized behavioral health interventions tailored to agitation and a persistent desire to go home. Care plans listed general strategies such as distraction with food, activities, and conversation, use of a wander guard, and medication administration, but lacked specific guidance on how staff should engage the resident when anxious, which coping methods were effective, what activities to use, or the level of supervision needed. The resident’s room contained minimal personal belongings or activities despite the resident reporting a love of reading and activities. Staff described using additional distraction techniques, such as showing baby pictures, that were not reflected in the care plan, and the SW acknowledged not revising the behavioral care plan or collaborating with family to provide more familiar items, despite facility policy requiring comprehensive, person-centered care planning.
The facility failed to maintain an effective infection control program, leading to a COVID-19 outbreak among residents and incomplete staff illness tracking. Additionally, the whirlpool tub was not disinfected according to manufacturer's guidelines, potentially affecting resident safety. Interviews revealed deficiencies in documentation and follow-up procedures.
The facility failed to implement a comprehensive antibiotic stewardship program, lacking Antibiotic Time Outs (ATO) and evaluation of continued need for antibiotics for three residents. A resident received Macrobid for UTI prevention without urine cultures or sensitivity tests, and no ATO was conducted. Another resident's record lacked criteria documentation for Macrobid use, and a third resident's antibiotic treatment was changed due to a rash, but criteria were not documented prior to requesting antibiotics. Interviews revealed inconsistent documentation and implementation of criteria for antibiotic use, and the facility's policy was not effectively followed.
A facility failed to reassess a resident's PRN diazepam every 14 days, as required, to ensure its continued appropriateness. The resident, diagnosed with Alzheimer's and dementia with agitation, was on multiple psychotropic medications. Despite reminders in the Treatment Administration Record, there was no evidence of a timely review by the physician. Staff interviews confirmed the oversight, and the facility's policy lacked enforcement of medication duration.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Timely Report Resident Elopement as Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an incident of neglect, specifically an elopement, to the State Agency (SA) within the required two-hour timeframe. On 1/11/26, a resident identified as R1 self-propelled in a wheelchair toward the dining room door leading outside. Facility incident documentation indicated that R1 exited the building through the south exit door by the dining room; the wander guard alarm did not activate, and R1 was found approximately 15 feet outside the door. R1 was wearing two sweaters, shoes, and carrying a bag. Staff spent time attempting to calm and redirect R1 while outside, and R1 eventually agreed to return inside on the condition of being allowed to speak with the doctor. R1 was assisted back into the facility safely. Camera footage reviewed on 1/22/26 showed that at 9:17 a.m. on 1/11/26, R1 was in the wheelchair self-propelling toward and then through the dining room door to the outside, with two other residents present in the dining room and one staff member briefly entering to escort another resident out. Staff were observed joining R1 outside at 9:19 a.m., and R1 returned inside with staff at 9:29 a.m. The facility reported the incident to the SA at 2:40 p.m. on 1/11/26, which exceeded the two-hour reporting requirement. During interview, the DON stated she did not report within two hours because there was no harm to R1 and believed that when there was no harm, the reporting timeframe was 24 hours. The DON acknowledged that the facility policy and regulations, which require reporting alleged violations of abuse, neglect, exploitation, or mistreatment immediately but not later than two hours if involving abuse or serious bodily injury, and not later than 24 hours otherwise, were not followed.
Failure to Revise and Implement Elopement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to revise and implement care plan interventions for a resident with dementia who was at risk for elopement and exhibiting consistent exit-seeking behavior. The resident had diagnoses of cerebral infarction and unspecified dementia with behavioral disturbances, and an annual MDS identified moderate cognitive impairment with daily use of a wander/elopement alarm. A care plan dated 11/13/25 documented impaired thought processes, potential wandering, and exit seeking, with interventions such as cueing, reorientation, supervision, maintaining a consistent routine and caregivers, and use of a wander guard on the wheelchair. However, the care plan section related to elopement and safety lacked evidence of interventions directed to this risk. A subsequent care plan dated 1/11/26 identified the resident as an elopement risk due to prior attempts to leave unattended, impaired safety awareness, dementia, and memory impairment, and included general distraction interventions (activities, food, conversation, television, books), but no additional interventions were added despite a significant history of wandering and packing a suitcase with the intention of going home. The resident’s Wandering Risk Scale dated 10/23/25 documented a recent history of packing items in a suitcase intending to go home and being difficult to redirect, with a wander guard in place on the wheelchair. Progress notes showed that on 1/11/26 the resident became agitated, expressed a desire to go home, packed belongings, opened a door, and stepped outside into the snow before staff redirected the resident back inside; the wander guard had been changed the day before and was reported as functioning normally, but did not activate at the door. The medical record lacked evidence that care-planned interventions such as redirection, reorientation, or increased supervision were implemented prior to this elopement event, despite clear signs of elopement behavior. During interviews, the MDS RN and social worker reported that the IDT met after the elopement and reviewed the care plan, initially determining no changes were needed; upon review, the MDS RN acknowledged the care plan was not complete and should have included more specific interventions, and the social worker acknowledged not having recently worked with the family to develop a more personalized care plan, despite the resident being an avid reader and a hoarder with limited books in the room.
Elopement Risk Resident Exits Building Without Effective Wander Guard Alarm
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of an elopement alarm device for a resident at risk for elopement. The resident had diagnoses of cerebral infarction and unspecified dementia with behavioral disturbances, with an annual MDS identifying moderate cognitive impairment and daily use of a wander/elopement alarm. The resident’s care plans documented an elopement risk related to prior attempts to leave the facility unattended, impaired safety awareness, dementia, memory impairment, and exit-seeking behavior, including a history of packing belongings to go home and difficulty with redirection. Interventions included diversional activities, supervision as needed, consistent routines and caregivers, and use of a wander guard on the wheelchair. On the day of the incident, facility progress notes indicated the resident was agitated, wanted to go home, and had packed belongings. The resident managed to open a door and step outside into the snow. Camera footage later showed the resident self-propelling in a wheelchair toward the dining room door leading outside, pushing the door open, and exiting the building while two other residents and one staff member were present in the dining room. The staff member was observed escorting another resident out of the dining room and did not prevent the resident from exiting. The resident remained outside on campus until staff were observed with the resident and subsequently returned the resident to the building. The facility’s incident report documented that the resident exited through the south exit door by the dining room and that the wander guard alarm did not sound when the resident left. Observation later showed the resident’s wander guard pendant hanging under the wheelchair seat from a metal piece, secured by the wristband closure, rather than being worn on the wrist or ankle. The wander guard manufacturer’s manual specified that the strap was to be worn on the individual’s wrist or ankle, and a manufacturer representative stated that placing the pendant on metal could reduce effectiveness and cause malfunction. Interviews confirmed that the resident did not wear the pendant on the wrist or ankle, staff responsible for assessments had not reviewed the wander guard manual or verified safe alternative placement, and the DON was not aware that the pendant was required to be on the wrist or ankle, resulting in the device not being used according to manufacturer guidelines and failing to alert staff when the resident exited.
Failure to Develop Individualized Behavioral Health Strategies for Agitated Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary and individualized behavioral health care and services for a resident with dementia and behavioral disturbances, particularly related to agitation and a desire to go home. The resident had diagnoses of cerebral infarction and unspecified dementia with behavioral disturbances, with MDS documentation of moderate cognitive impairment and daily use of a wander/elopement alarm. Care plans identified the resident as an elopement risk with impaired safety awareness, memory impairment, potential wandering, exit seeking to go home, and multiple behavior problems including hoarding, yelling, verbal abuse, twisting staff wording, fabricating stories, and rejection of care. Interventions listed included distraction with pleasant diversions, structured activities, food, conversation, television, books, cueing and reorientation, consistent routines and caregivers, use of a wander guard, administering medications, anticipating and meeting needs, and assisting the resident to develop more appropriate coping methods. However, the care plans lacked specific strategies on how staff were to engage the resident when anxious, what coping methods were actually successful, what activities were most effective, and what level of supervision was necessary to maintain safety. Surveyor observations and staff interviews further demonstrated the lack of individualized behavioral health strategies. The resident’s private room contained limited personal belongings or activities despite the resident stating she loved to read, enjoyed activities, wanted to return home, and felt she did not need facility care. The resident reported having nothing to do in the room. An RN acknowledged that care plan revisions had not been completed since an elopement incident and was not aware of staff using interventions beyond those listed in the care plan, though she noted the resident attended activities that could be helpful when agitated. An LPN described using pictures of babies and talking about motherhood to distract the resident when agitated, but this intervention was not included in the care plan and was not consistently effective. The social worker, who developed the behavioral portion of the care plan, stated she did not find it necessary to revise it and believed there was nothing more to personalize, despite acknowledging the resident was an avid reader, had only a couple of books in the room, and that the facility had not worked with the family to update the care plan or explore bringing in more familiar items from home. This was inconsistent with the facility’s own policy requiring person-centered care plans based on careful data gathering and individualized interventions addressing underlying causes rather than just symptoms.
Inadequate Infection Control and Tub Disinfection Procedures
Penalty
Summary
The facility failed to maintain a current and effective infection prevention and control program, which led to a COVID-19 outbreak affecting 17 out of 32 residents between December 15, 2024, and January 20, 2025. The infection control logs for residents did not document the date and type of transmission-based precautions (TBP) or when these precautions were implemented. Additionally, the staff infection control logs were incomplete, lacking follow-up information, potential testing, and clearance for staff to return to work after illness. Interviews with the Director of Nursing (DON) and other staff confirmed the deficiencies in documentation and follow-up procedures. The staff infection control logs for November 2024 showed multiple instances of staff reporting illness, including symptoms consistent with COVID-19, but lacked documentation of follow-up actions, testing, or clearance for returning to work. The infection preventionist acknowledged the incomplete tracking of employee illnesses and the absence of a process for determining when staff could safely return to duty. Interviews with various staff members revealed inconsistencies in the documentation and follow-up process for staff illnesses, contributing to the potential spread of infection within the facility. Furthermore, the facility failed to ensure proper disinfection of the whirlpool tub used by residents. The environmental services manager and nursing assistant responsible for cleaning the tub did not follow the manufacturer's guidelines for disinfection, which required a specific amount of disinfectant to be infused into the water and surfaces to remain wet for a designated time. The Director of Nursing was unaware of the absence of posted instructions for cleaning the tub and confirmed that staff were not following the manufacturer's guidelines. This oversight had the potential to affect the health and safety of residents using the whirlpool tub.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, specifically lacking the execution of Antibiotic Time Outs (ATO) and evaluation of continued need for antibiotic treatment for three residents. Resident 6 had a physician order for Macrobid for UTI prevention, but the medical record did not show any urine cultures or sensitivity tests completed following the order, nor any ATO for continued need of the medication. Additionally, there were no non-pharmacological interventions attempted. Resident 15's medical record showed an order for Macrobid for a UTI, but lacked documentation of criteria implemented or an ATO. Resident 28's record indicated an order for Macrobid, which was later changed to Ertapenem due to a rash, but there was no documentation of criteria prior to requesting a UA and antibiotics, and ATOs were not completed during this period. Interviews with the Director of Nursing (DON), medical director, and infection preventionist (IP) revealed that there was a lack of consistent documentation and implementation of criteria for updating providers before requesting antibiotics for UTIs. A meeting was held to discuss antibiotic stewardship and criteria for antibiotic use, but no actions were implemented prior to the survey. The IP was unaware that the criteria were not being utilized and that ATOs were not being completed according to facility policy. The facility's Antibiotic Stewardship Policy required monthly tracking and review of antibiotic use, but this was not being effectively implemented, leading to the identified deficiencies.
Failure to Reassess PRN Diazepam Every 14 Days
Penalty
Summary
The facility failed to reassess a resident's as-needed (PRN) anti-anxiety medication, diazepam, every 14 days to ensure the appropriateness of its continued use. The resident, who had diagnoses of Alzheimer's and dementia with agitation, was cognitively impaired and received antipsychotic, antianxiety, and antidepressant medications daily. The diazepam was ordered and started on November 8, 2024, but there was no indication that the physician had limited the order to 14 days for review. The December 2024 Medication Administration Record (MAR) showed diazepam was to be given every 8 hours as needed, but lacked an end date. Progress notes indicated that the medication was reviewed on November 26, 2024, and December 10, 2024, but there was no documentation of a review by December 24, 2024, as required. The Treatment Administration Record (TAR) included reminders for staff to notify the physician to review the diazepam every 14 days, but there was no evidence that this was done before January 15, 2025. Interviews with staff, including licensed nurses and the medical director, confirmed that the PRN order should have been reviewed every 14 days. The facility's psychotropic medication usage policy required monitoring and evaluation of the effectiveness of such medications, but did not specify how the duration of use was enforced. The director of nursing expected staff to notify the physician of the absence of a stop date and the need for re-evaluation of the medication for continuation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Appleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Healthcare Services | 15.3 mi | ★★★★★ | 10 | 0 |
| Johnson Memorial Hospital & Home | 18.7 mi | ★★★★★ | 2 | 0 |
| Luther Haven | 22.4 mi | ★★★★★ | 2 | 0 |
| Fairway View Neighborhoods | 22.5 mi | ★★★★★ | 1 | 1 |
| West Wind Village | 27.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Appleton Area Health.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.