Edenbrook Of Appleton North

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and monitoring for a resident with a known history of elopement and WanderGuard (WG) removal. The resident had diagnoses including dementia, seizure disorder, schizoaffective disorder, and bipolar disorder, and a protective placement document on file requiring placement on a secured unit due to prior absconding attempts and inability to assure safety on an unsecured unit. The resident’s care plan identified elopement and wandering risk, with interventions such as WG placement, monitoring/documenting wandering episodes and triggers, and adding the resident to an elopement risk list. Despite this, an initial elopement risk assessment rated the resident as low risk, later revised to at risk and then high risk, and the facility did not consistently increase supervision or monitoring in response to repeated elopement attempts and WG removals. Over several weeks, the resident repeatedly attempted or succeeded in leaving the facility or its immediate grounds. On multiple occasions, staff documented the resident walking up and down hallways with belongings piled on a wheelchair, locking in a guest restroom with personal items, and exiting to the front of the building or parking lot, sometimes in cold weather and without appropriate clothing. The resident cut off the WG on several dates, and staff reapplied new WGs but did not implement increased supervision or more frequent WG checks, nor did they determine or address how the resident was obtaining tools (such as scissors) or otherwise removing the device. The facility placed a WG on the resident’s wheelchair despite knowing the resident historically cut off the WG and despite manufacturer recommendations discouraging placement near metal due to interference with radio frequency. Staff also did not consistently implement individualized interventions listed in the care plan, such as offering to take the resident outside, engaging in conversations about religion or crafts, or checking daily for needed items from outside the facility. On one occasion, the resident left the building without a walker or wheelchair, attempted to get into a visitor’s vehicle, and was brought back inside after staff were alerted by the visitor; the WG had been cut off and was later found on a unit. On another occasion, the resident exited the facility, and staff and police were unable to redirect the resident back inside immediately. The most serious event occurred when the resident was last seen in the dining room and later could not be found during rounds; staff initiated a search and located the resident in the bathroom of a nearby business across a busy street, in cold and dark conditions, after the resident had cut off the WG and hidden it in the lobby. The facility’s own investigation acknowledged that the door alarm did not sound because the WG had been removed and hidden, and that the facility could have potentially failed to keep the resident safe. Review of treatment administration records showed multiple shifts with missing documentation of required WG placement and function checks, and a gap of several days with no documented WG checks after the resident returned from the hospital. Facility leadership acknowledged that they did not attempt to increase supervision or WG checks despite multiple elopement attempts and WG removals, and staff interviews confirmed that individualized wandering and elopement interventions were not consistently carried out. These failures led to a finding of immediate jeopardy beginning on 11/6/25.

Removal Plan

• Reviewed and revised care plans for all residents who display exit seeking behavior and/or scored at risk on their Elopement Risk Assessment.
• Reviewed the facility's Elopement Risk and Prevention policy and procedure to ensure it meets current standards of practice.
• Educated staff on ensuring each resident receives adequate supervision and assistive devices to prevent accidents; the facility's Elopement Risk and Prevention policy; how to properly respond and interventions to put in place if a resident exit seeks, leaves the facility, removes a WG, or searches for or is provided tools to remove a WG.
• Implemented elopement audits and elopement drills.
• Reviewed and updated the Facility Assessment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a deep tissue injury (DTI) on the right heel did not receive wound care as ordered. The resident had a physician's order for daily dressing changes, which was documented in the medical record and the facility's policy required staff to verify and follow such orders. However, review of the Treatment Administration Record (TAR) showed that the dressing change was not completed on a specific date. The Director of Nursing confirmed that the daily wound care order was not followed and acknowledged that the dressing change should have been performed and documented daily. The resident had multiple diagnoses, including sepsis, cellulitis of the right lower limb, a non-pressure chronic ulcer with fat layer exposed, and an abrasion of the left elbow. The resident's cognitive status was moderately impaired, and a Power of Attorney for Healthcare was in place. A Nurse Practitioner documented that the right heel wound had deteriorated, with significant eschar and slough present, and attributed the decline to nutritional compromise. Despite the wound's condition and the clear orders for daily care, the required dressing change was missed, constituting a failure to provide appropriate pressure ulcer care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that appropriate fall interventions were in place for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident with multiple diagnoses including impaired mobility, cognitive impairment, and use of anticoagulant medication, the care plan was not updated with an immediate intervention following a fall. Although the interdisciplinary team later reviewed the incident and identified that the resident attempted to self-transfer while wearing Prevalon boots, which contributed to the fall, there was no evidence that an immediate intervention was added to the care plan as required by facility policy. For another resident with severe cognitive impairment and a history of falls, the care plan included an intervention to have a urinal at the bedside after a previous fall. However, during the survey, the resident was observed in bed without a urinal at the bedside, and staff confirmed that the intervention was not consistently followed. The Director of Nursing acknowledged that fall interventions should be in place but was unsure if the resident was capable of using a urinal, indicating a lack of consistent implementation of the care plan intervention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food was not stored, prepared, cooled, or sanitized in accordance with professional standards. During kitchen observations, surveyors found multiple pre-cooked foods in the walk-in cooler that were unlabeled, undated, or not clearly identified, including containers of ground meat, red sauce, roast beef, puree fish, puree peas, puree turkey, and taco meat. Staff confirmed that some foods were left out on counters or carts to cool before being placed in the cooler, and the dietary manager could not confirm when several items were cooked, cooled, frozen, thawed, or placed in the cooler. The facility’s cooling log did not include several of the observed items, and one logged item showed oatmeal at 140 degrees F and then 80 degrees F in the second hour without documenting when cooling started or ended or that the food reached 70 degrees F. Surveyors also observed expired, undated, or improperly stored items in dry storage and the walk-in cooler. These included undated boxes of Cream of Wheat, expired cans of bean sprouts and chow mein noodles, a dented can of sliced apples, an undated bin of brown rice with a Styrofoam bowl used as a scoop, a container of white sugar with a condiment cup used as a scoop, an unlabeled container of white powder, and several unlabeled containers of cereal. The dietary manager stated that these items should not be in dry storage, that food removed from its original container should be labeled and dated, that thickener should be dated, and that scoops should not be stored in food containers. The manager also stated that undated food should be discarded and that leftovers or food pulled from the freezer should be dated and discarded after seven days. The facility also did not document sanitizer water temperatures or verify warewashing surface temperatures as required. A dish room sanitizer log had a place to record water temperature, but no temperatures were entered. The dietary manager confirmed the facility used Hydrion Quaternary test strips and that the water temperature used to mix the sanitizing solution was not tested before use. In addition, the dishwasher temperature log showed missing daily surface temperature documentation for several days, and the dishwasher disc used to check surface temperature could not be used because the battery was dead. The dietary manager was unsure when the battery died and confirmed staff were required to obtain and document surface temperatures daily. July and August dishwasher logs showed documented surface temperatures that did not reach 160 degrees F.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for four residents. During observed pericare for a resident with end stage renal disease and a permacath, a CNA donned gown and gloves but, after cleansing the resident’s buttocks and rectal area, touched the resident’s clean brief, Chux pad, shirt, bedding, bedside table, water pitcher, and bed control without removing gloves and performing hand hygiene. The CNA later confirmed the gloves should have been removed and hand hygiene completed after pericare, and the DON agreed. A resident on enhanced barrier precautions underwent catheter irrigation by an LPN who completed hand hygiene and donned gloves, but did not wear a gown during the procedure. The LPN opened saline syringes and alcohol prep pads, removed gloves, performed hand hygiene, donned clean gloves, and continued the irrigation. The LPN later stated a gown should have been worn, and the DON verified that a gown should have been used for the catheter irrigation. For another resident on enhanced barrier precautions due to ESBL history, a CNA was observed exiting the resident’s room in a gown and gloves, entering a utility room, disposing of trash, and then removing the gown and gloves without completing hand hygiene before leaving the utility room. A fourth resident with a Foley catheter, chronic UTIs, ESBL resistance, and flaccid neuropathic bladder had an uncovered catheter bag observed on the floor. The DON stated catheter bags should not be on the floor and should be covered with a dignity bag.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that two residents received necessary care and services to prevent or monitor significant weight loss. The facility policy stated that significant weight change is defined as a 5% loss over 30 days, a 7.5% loss over 90 days, or a 10% loss over 180 days, and that significant unplanned weight loss should be communicated and addressed with interventions and care plan updates. Surveyor review found that R11, who had diagnoses including Alzheimer's disease, moderate protein-calorie malnutrition, and irritable bowel with constipation, had a 6.1% weight loss from 6/2/25 to 7/1/25 after being admitted following hospitalization for adult failure to thrive. R11's care plan identified a potential for altered nutritional status and included interventions such as a regular diet, dietitian evaluation, and weighing per facility policy. A weight change note documented the significant loss and indicated nursing was notified to re-weigh R11, but the next documented weight was not until 8/1/25. The RD and DON confirmed that the re-weigh was not completed when requested and that no interventions were implemented for the significant weight loss, and the care plan had not been revised since 6/9/25. R8, who had diagnoses including aftercare after joint replacement surgery, depression, history of traumatic brain injury, schizophrenia, and alcohol abuse, made own medical decisions and had intact cognition. R8's record showed a weight of 210.4 pounds on 7/1/25 and 195.4 pounds on 8/1/25, a 7.1% loss in one month. Although an RD note earlier described a 10% weight loss over 180 days as favorable and intake was generally 50-100% of meals, the RD later verified that R8 should have been flagged for weight loss and that the flag had been cleared. The RD stated R8 should have been re-weighed immediately, and the DON stated the nurse should have had the resident re-weighed and entered the correct weight in the medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Ensure each resident's drug regimen must be free from unnecessary drugs was not met when the facility did not monitor one resident, R29, for side effects or adverse reactions to ciprofloxacin. R29 was most recently admitted with diagnoses including dementia, diabetes, a chronic ulcer of the right lower leg, MRSA leg wound, and ESBL resistance. R29's MDS assessment dated 7/11/25 indicated intact cognition and that R29 made their own healthcare decisions. A right lateral shin culture dated 7/22/25 indicated MRSA requiring isolation. R29 was prescribed ciprofloxacin HCl 500 mg by mouth twice daily for a wound infection for 7 days on 7/29/25. The care plan noted a history of ESBL and included interventions for enhanced barrier precautions and antibiotic per MD order, but it did not include orders or interventions to monitor for side effects or adverse reactions to ciprofloxacin. The facility's Antibiotic Stewardship Policy stated the nurse will observe and document effectiveness of antibiotics, side effects, and potential adverse consequences, and that the resident will be observed for potential side effects of the antibiotic. The DON confirmed R29 had an order for ciprofloxacin and that R29 should have orders and interventions in the plan of care to monitor for side effects and adverse reactions to ciprofloxacin.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the presence of expired sanitizing wipes and hand sanitizer on PPE carts designated for residents on enhanced barrier precautions. During observations, surveyors found multiple instances of expired bleach wipes and hand sanitizer in resident care areas and storage, with expiration dates ranging from the previous year to several years prior. Staff were seen replacing expired products only after surveyor observation, and there was no evidence of a systematic process for checking or removing expired items from use. Interviews with staff, including a nurse schedule coordinator, a registered nurse, a housekeeper, the director of nursing, and the nursing home administrator, revealed a lack of knowledge regarding the effectiveness of expired infection control products and uncertainty about who was responsible for monitoring expiration dates. The facility's infection control policy required regular evaluation and enforcement of proper infection control practices, but staff were unable to demonstrate adherence to these requirements, resulting in the continued availability and use of expired infection control supplies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a home-like dining experience for its residents, as required by its own Dining and Food Service policy. Surveyors observed that meals were served on disposable Styrofoam dishware in several wings, rather than on non-disposable plates. Multiple staff members, including CNAs and dietary staff, confirmed that disposable dishware had been used for several months, primarily due to kitchen staffing shortages. The Director of Nursing was unaware of the ongoing use of disposable dishware, and the Nursing Home Administrator was only partially aware, knowing that sandwiches were served in foil but not that all meals were being served on disposables. Residents with intact cognition, including those with diagnoses such as metabolic encephalopathy, asthma, diabetes, and congestive heart failure, expressed dissatisfaction with the dining experience. One resident stated a preference for real plates and indicated a desire to be asked about eating in the dining room, even though they preferred to eat in their room. Another resident, who had difficulty walking, expressed a wish to be offered the option to eat in the dining room and to be assisted there by staff. These preferences were not routinely solicited or accommodated by facility staff. Surveyors directly observed that while some meals in the 100 wing dining room were served on non-disposable plates, dinner service in the 300 and 400 wings, as well as supper in the 100 wing dining room, utilized disposable dishware. Some food items were not covered, and sandwiches were served in foil wrappers. Staff interviews confirmed that the use of disposable dishware was a directive from the Dietary Supervisor due to staffing issues, and that this practice had been ongoing for several months. The facility's failure to provide a home-like dining environment and to offer residents choices regarding their dining location constituted a deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency identified in the report pertains to the inaccurate and untimely posting of nurse staffing information at the facility. The facility's policy requires that nurse staffing information, including the number of licensed and unlicensed direct caregivers and their hours worked per shift, be posted at the beginning of each shift in a clear and readable format. However, the surveyor observed that the nurse staffing posting did not accurately reflect the actual number of nursing staff working during the night shift on December 12, 2024, and was not updated at the start of the morning shift on December 13, 2024. Specifically, the posting indicated there were four Certified Nursing Assistants (CNAs) plus one CNA in training, but only three CNAs were present due to a call-in. Additionally, the posting for December 12, 2024, remained displayed well into the morning of December 13, 2024, without being updated to reflect the current staffing. Further investigation revealed that the facility did not post nurse staffing hours on weekends. The Nurse Scheduler (NS) confirmed that the postings for Saturday and Sunday were prepared on Friday and any changes were updated on Monday, indicating a lack of real-time updates during the weekend. This practice was corroborated by the Nursing Home Administrator (NHA), who acknowledged the absence of weekend postings and the need to develop a process for posting nurse staffing hours on weekends. The failure to update the postings in a timely manner and the absence of weekend postings had the potential to affect all 67 residents residing in the facility, as accurate staffing information is crucial for ensuring adequate care and transparency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide accurate pharmaceutical services for a resident, identified as R276, who missed three doses of antirejection medication over a three-day period due to a lack of clarification on the proper dosage. The resident, who had undergone multiple kidney and pancreatic transplants and was diagnosed with end-stage renal disease, was prescribed cyclosporine to be administered twice daily. However, the facility's staff administered the medication only once per day, as per the initial hospital discharge orders, without verifying the updated dosage instructions. This discrepancy led to the resident using their home supply of medication, as the facility's staff could not locate the delivered medication. Interviews with the resident, family member, and facility staff revealed that the resident had repeatedly questioned the nursing staff about the missing evening doses, but the staff did not seek clarification from the physician. The Director of Nursing and Assistant Director of Nursing acknowledged the staff's confusion regarding the medication's storage location and confirmed that the antirejection medication is life-sustaining. Despite the medication being available at the facility, it was not administered correctly due to miscommunication and improper storage, resulting in the resident's frustration and reliance on their home supply.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure protective placement for a resident, identified as R49, who had a legal guardian and was admitted with several medical conditions including vascular dementia, hemiplegia, hemiparesis, and aphasia. The resident was admitted on March 10, 2023, and had a guardianship filed on April 26, 2023, due to incompetency. However, the facility did not petition or obtain court-ordered documents for protective placement, which is required when a resident's stay exceeds 60 days. This oversight was identified during a survey conducted between June 10 and June 12, 2024. The surveyor's review of R49's medical record revealed that the resident was rarely understood and had severely impaired cognition, with short and long-term memory problems and poor recall ability. Interviews with the Director of Nursing and the Social Service Director confirmed that protective placement was not obtained for R49. The Social Service Director had previously contacted the resident's guardian ad litem, who confirmed that R49 was not protectively placed, and no further action was taken to file a petition for protective placement with the county.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy by not ensuring a timely background check for a Certified Nursing Assistant (CNA-C). CNA-C was hired on November 10, 2015, and the most recent background check on file was dated November 8, 2019, which was not within the required four-year timeframe. The facility's policy mandates screening potential employees for a history of abuse, neglect, exploitation, or mistreatment, including obtaining information from previous employers and checking with licensing boards and registries. On June 11, 2024, the Director of Nursing (DON-B) acknowledged to the surveyor that CNA-C's background check was only run on that day because the Human Resources department did not have a recent one on file. DON-B confirmed that the background check should have been completed sooner, indicating a lapse in following the facility's policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a Preadmission Screen and Resident Review (PASRR) was updated for a resident after a significant change in their mental health condition. The resident, identified as R26, was initially admitted with diagnoses including bipolar disorder, anxiety disorder, borderline personality disorder, and depression. A PASRR Level I Screen was completed upon admission, and a Level II Screen was conducted later. However, after the resident was diagnosed with chronic paranoid schizophrenia and prescribed Vraylar, an antipsychotic medication, the facility did not update the PASRR Level I Screen or submit a new referral for a Level II Screen. The deficiency was identified during a survey conducted from June 10, 2024, to June 12, 2024. The Social Services Director, who was not employed at the time the new PASRR Level II Screen should have been obtained, confirmed that no additional Level II referral was submitted following the new diagnosis and medication prescription. The Behavioral Consulting Services Consultant also confirmed that a new referral should have been submitted due to the change in the resident's mental illness diagnosis.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to droplet precautions for residents R19 and R28. On multiple occasions, staff entered the rooms of these residents without performing hand hygiene or donning the required personal protective equipment (PPE), such as gowns, gloves, and face masks, despite clear signage indicating droplet precautions. Staff members, including a hospitality aide and certified nursing assistants, were observed entering and exiting the rooms without the necessary precautions, and some staff were unaware of the requirements for PPE use under droplet precautions. Additionally, the facility did not implement enhanced barrier precautions (EBP) for resident R5, who had a stage 3 pressure injury. Despite the resident's care plan indicating the need for EBP, there was no signage, PPE cart, or garbage can for PPE disposal near R5's room. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that a resident with a stage 3 pressure injury should be on EBP, yet these measures were not in place for R5. The Director of Nursing and the Assistant Director of Nursing, who also served as the Infection Preventionist, acknowledged the lapses in infection control practices. They confirmed that staff should have donned and doffed PPE when entering and exiting the rooms of residents on droplet precautions and that residents on EBP should have appropriate signage and equipment available. The failure to adhere to these protocols indicates a significant deficiency in the facility's infection prevention and control program.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that vaccinations were reviewed, offered, or administered for two residents, R14 and R40, as per the CDC guidelines and the facility's own vaccination policy. R14, who had a Power of Attorney for medical decisions, was due to receive the PCV20 vaccine on October 29, 2020, five years after their last pneumococcal vaccine. Despite having signed consent forms from the POA on September 15, 2023, and February 22, 2024, the facility did not administer the vaccine to R14. R14's medical record did not indicate that the PCV20 vaccine was administered, highlighting a lapse in following through with the vaccination process. Similarly, R40, who had a legal guardian, was due to be offered the PCV20 vaccine on July 18, 2022. Although R40's medical record contained appropriate signed consents for pneumococcal vaccines prior to this date, there was no indication that R40 was offered or administered the PCV20 vaccine after becoming eligible. The medical record also lacked documentation of the vaccine being received elsewhere. Interviews with the facility's Assistant Director of Nursing and Director of Nursing revealed that the facility's policy was to verify vaccination status through the Wisconsin Immunization Record and to offer vaccines per CDC recommendations. However, the facility did not adhere to these procedures, resulting in the deficiency.