Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Meadowbrook At Appleton during CMS and state inspections, most recent first.
After the departure of the previous Dietary Manager, the Administrator—who lacked required food service certification—assumed the role, contrary to facility policy. The Registered Dietitian was not full time, and the absence of a certified Dietary Manager had the potential to impact food and nutrition services for all residents.
A resident with a history of hallucinations had their atypical antipsychotic medication dose increased, but the facility failed to notify the resident's representative of this change as required by policy. Documentation confirming notification was not found, and the Administrator was unable to provide evidence that the notification occurred.
Food was not stored and prepared in a sanitary manner when surveyors found multiple cooked items and leftovers in the reach-in cooler with no food cooling log or documentation that they were cooled using approved methods. Surveyors also found that the sanitizer log for the 3-compartment sink did not document Quat PPM or water temperature, and the DM confirmed staff were taping test strips to the log instead of recording accurate readings.
Food was not ensured to be palatable and served at an appetizing temperature for multiple residents. Several residents with diagnoses including DM, COPD, dementia, ESRD, CKD, and dysphagia reported that meals arrived cold or lukewarm, and one observed test tray showed lunch items at 123-127 degrees F. The DM acknowledged resident complaints about cold food, was unsure whether the plate warmer was working or plugged in, and the plate warmer was found unplugged and nonfunctional during observation.
Failure to Document Resident Participation in Care Planning: Three residents did not have documentation of care conferences in their medical records, and each resident stated they had not been involved in care planning or had not been informed of any care conference. The SSD-M said the residents had care conferences, but no documentation could be found, and both the SSD-M and DON stated care conferences should occur quarterly.
Failure to obtain or offer POAHC documentation for a resident. A resident’s record lacked POAHC paperwork and a refusal form, even though the resident said the document was at home and family had access to it. The SSD also confirmed the resident reported an advance directive was in a safe at home, and the record showed only one documented request to a family member for a copy, with no further documented attempts. The DON stated staff are expected to obtain the POAHC document or offer to create a new one.
A resident with intact cognition and diagnoses including pressure ulcers and paraplegia reported that the room was dirty and the trash was overflowing. Surveyors observed clothing and linens stacked on the HVAC register, dirt and food debris on the floor, used wound-cleaning items and lancet tops left on the floor, and an overflowing garbage can containing used PPE and food. The same conditions remained on repeated observations, and the MD confirmed resident rooms should be cleaned daily but this room was not cleaned.
Incomplete bowel and bladder care plan: A resident with schizophrenia, dysphagia, depression, diabetes, and moderate cognitive impairment was documented by MDS as occasionally incontinent of bladder and without a toileting program, yet the comprehensive care plan did not include problems, goals, or interventions for incontinence. CNA charting showed nighttime urinary incontinence, while a CNA reported the resident was continent and independent with toileting. The DON confirmed the care plan omission.
A resident with severe cognitive impairment, cerebrovascular disease sequelae, dysphagia, hemiplegia, and hemiparesis fell and was found on the floor between the bed and window with a head laceration. After the fall, the care plan required the bed to remain in the lowest position, but surveyors later observed the bed in the highest position and then in a medium height position, and staff confirmed it was not being kept as directed.
Improper Catheter Bag Placement: Two residents with indwelling catheters had drainage bags observed on the floor. One resident had a recent UTI, neurogenic bladder, paraplegia, and pressure ulcers, and stated the uncovered bag should not be on the floor and should be covered with a dignity bag. Another resident with severe cognitive impairment had the catheter bag on the floor when the bed was lowered. Staff and the DON acknowledged catheter bags should not touch the floor, and facility policy and CDC guidance required the bag to remain below the bladder and off the floor.
Failure to verify feeding tube placement before enteral medication and feeding. Two residents with PEG/G-tubes received enteral meds and feeding without staff checking tube placement or residual as required by facility policy and orders. One RN administered acidophilus and Jevity through a PEG tube without confirming placement, and an LPN gave crushed medication via G-tube without checking placement first.
A resident with chronic pain, bilateral DVTs, neuropathy, and intact cognition did not receive effective pain management when a Fentanyl patch ordered to be changed every 3 days was found overdue and remained in place past the scheduled change date. The resident reported pain, achiness, and poor sleep, and stated non-pharmacological interventions were not offered. The DON confirmed the patch had not been re-ordered before the last one was used, and the MAR showed ongoing PRN oxycodone use with pain often rated 5 to 7 out of 10.
Failure to Follow Droplet Precautions: A resident with sepsis, pneumonia, and a UTI due to E-coli was placed on droplet precautions, but staff did not use the required PPE when entering the resident's room. A CNA entered with an oxygen tank without donning PPE, and housekeeping later changed linens without gloves or a mask while the resident was present. The DON confirmed staff should have worn a mask and that the observed practice did not follow facility policy.
A resident reported a painful bug bite on the R hand and said fruit flies were everywhere in the building; the surveyor also observed several fruit flies in the resident’s room. Record review and staff interviews showed the facility had no current pest control contract, no documentation of regular pest control visits, and had not had pest control service since February.
A resident with a stage 4 pressure injury and a wound vac experienced worsening of the wound after a nurse applied the wound vac dressing incorrectly, omitting the protective drape layer. This resulted in skin erosion and an increase in wound size, as confirmed by a wound nurse practitioner. Staff interviews revealed that the nurse was unaware of the error until informed by the resident and had not received timely education on proper wound vac application. Other staff also reported a lack of prior education on wound vac procedures.
Surveyors found that several medications, including inhalers, nasal spray, and topical treatments, were left at the bedsides of four residents without the required physician's orders or completed self-administration assessments. In each instance, the necessary documentation to authorize self-administration or bedside storage was missing, and the DON confirmed these lapses.
Surveyors identified that the facility failed to maintain a safe and sanitary environment by leaving a garbage dumpster open and uncovered, with discarded furniture nearby, and by not repairing uneven, cracked concrete and lifted floor tiles at the main entrance. These deficiencies were observed on multiple occasions and confirmed by maintenance and nursing leadership.
A resident with severely impaired cognition and an activated POAHC was given several psychotropic medications before informed consent forms were signed, and there was no documentation of verbal consent prior to administration. The facility's policy required informed consent and education before starting these medications, but this process was not followed, as confirmed by the DON.
A resident reported a missing blue jacket valued at $75 after discharge, but the facility's investigation was incomplete due to the lack of a personal inventory form and absence of staff education on misappropriation and property documentation, as required by facility policy.
A resident dependent on staff for ADLs, including oral care and pericare, did not consistently receive timely assistance during preferred morning hours, despite clear communication of preferences and repeated requests. Documentation and interviews showed that staff provided morning care only a fraction of the time, contrary to facility policy and the resident's care plan.
A resident with a PICC line did not receive a required weekly dressing change as ordered and per facility policy. Documentation showed the dressing was not changed by staff during the specified week, and a clinic RN later found the dressing dirty and peeling, prompting an unscheduled change. The DON confirmed the missed dressing change, resulting in a deficiency for failure to provide appropriate care.
A resident with multiple respiratory conditions did not receive proper care for their BiPAP machine, as the equipment was not cleaned according to facility policy and there was no documentation of regular maintenance. Staff confirmed that the cleaning occurred only once since admission, and the required cleaning schedule was not followed or documented.
A resident with dysphagia and a physician's order for a mechanical soft diet was served regular texture roast beef instead of the required minced and moist form. Despite clear dietary orders and meal ticket instructions, staff plated and delivered the incorrect food texture, which was confirmed by the Dietary Manager.
A resident's legal representative raised concerns about hygiene, showers, blood sugar monitoring, and financial bills following a respite stay. The Social Worker received these concerns and stated they were relayed to the DON, but no grievance was documented, investigated, or resolved, and there was no follow-up with the representative, contrary to facility policy.
The facility did not have a qualified director of food and nutrition services, as the Dietary Manager (DM-C) was promoted without completing the necessary certification. DM-C, who had no prior experience, was working towards certification with assistance from the NHA and RD, but required an extension due to not completing the course on time and a mentor change. The RD was not onsite full-time, affecting oversight.
The facility failed to meet the nutritional needs of residents on carbohydrate-controlled diets by serving regular dessert portions and not adhering to specified portion sizes. Dietary staff used incorrect scoop sizes, and there was no guidance on appropriate serving sizes. A dietitian confirmed the staff did not follow diet orders, leading to uniform portions for all residents.
A resident with moderate cognitive impairment experienced unwitnessed falls, and the facility failed to complete neurological checks as per policy. The resident's medical record indicated a risk for falls, yet staff missed several required checks after each fall. The DON confirmed the checks were incomplete, acknowledging the failure to adhere to the facility's policy.
The facility failed to ensure food was stored and prepared in a sanitary manner, affecting all 40 residents. There was no system for monitoring cooked food temperatures or hot/cold holding temperatures, and staff did not consistently document these temperatures. Additionally, staff did not wear hair and beard restraints while cooking and serving food, as required by the facility's policy. These deficiencies indicate a lapse in compliance with food safety standards.
The facility's Dietary Manager, recently promoted from a Dietary Aide position, had not completed the required certification or training for the role. The Nursing Home Administrator was aware of this deficiency and was working with the Regional Dietitian to set up training, which had not been initiated until the surveyor's visit.
The facility failed to ensure food was stored and prepared in a sanitary manner, affecting 47 of 48 residents. Issues included improper cooling temperature monitoring, inadequate handwashing sink temperature, unclean can opener, soiled oven mitts, improper chemical storage, uncovered food transport, lack of sanitizing solution testing, and improperly labeled or expired food items.
The facility's designated Infection Preventionist, the DON, did not complete the required specialized training in infection prevention and control, as they failed the certification test and missed the deadline to retake it. An ADON was hired to eventually assume the IP role, but had not yet started. This affected all 48 residents.
A resident was not offered the opportunity to create or obtain Power of Attorney for Health Care (POAHC) paperwork upon admission. The facility's policy requires inquiry and documentation of advance directives at admission, but the resident's POAHC document was not obtained or offered until months later. The refusal document was backdated, and the resident's signature was obtained on the day of the surveyor's visit.
A resident with severe cognitive impairment fell in their room, and the facility failed to notify the Power of Attorney for Healthcare (POAHC) as required by their Fall Management policy. The POAHC only learned of the fall during a visit and confirmed the incident with the staff.
The facility failed to provide written transfer notices to two residents who were hospitalized, despite having a policy in place. Staff were unaware of the requirement, and the necessary documentation was not provided.
The facility failed to provide written notification of the bed hold policy to two residents when they were transferred to the hospital. Both residents, who had significant medical conditions, did not receive the required documentation, as confirmed by staff interviews and medical record reviews.
The facility failed to complete a comprehensive assessment after a resident started Hospice services, as required by CMS guidelines. The Nursing Home Administrator confirmed the oversight.
The facility failed to develop a comprehensive baseline care plan for a resident within 48 hours of admission, omitting critical information on dialysis, diet, and smoking status. Interviews with staff revealed inconsistencies and a lack of awareness regarding the resident's care needs.
A resident who began Hospice services did not have a comprehensive care plan or physician's order for Hospice care until nearly two months later. The deficiency was confirmed through interviews and record reviews.
The facility failed to provide adequate post-fall monitoring for a resident with severe cognitive impairment and high fall risk. Required neurological checks were not fully completed following the resident's unwitnessed falls, as confirmed by the DON.
The facility failed to routinely clean respiratory equipment for two residents. Both residents had significant medical conditions requiring CPAP and oxygen therapy, but their medical records lacked necessary orders and care plans for equipment cleaning. Staff confirmed the absence of these orders and care plans, and observations revealed that the equipment was not properly maintained.
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident requiring daily peritoneal dialysis. The resident's daily weight was not recorded on 8 out of 38 days, and the facility did not notify the physician or dialysis center when the resident's weight exceeded specified parameters. Staff interviews and record reviews confirmed these deficiencies.
The facility failed to ensure a licensed pharmacist performed monthly drug regimen reviews for a resident over several months and did not act on pharmacy recommendations in a timely manner. The resident had a potential drug interaction that was not addressed promptly, contributing to the deficiency identified by the surveyor.
The facility failed to ensure proper infection control measures for two residents. A CNA assisted a resident without wearing PPE despite droplet precautions, and an RN used contaminated scissors during wound care. Both staff members also failed to properly remove their face masks, demonstrating a lack of adherence to infection control protocols.
The facility failed to review, offer, and administer influenza B and pneumococcal vaccinations for three residents. The Director of Nursing acknowledged the lapse, and the Regional Consultant confirmed missing documentation for the affected residents.
The facility failed to document COVID-19 immunization for three residents and did not implement a COVID-19 immunization program for staff. Interviews revealed that staff were not provided with information or offered the vaccine, and the Director of Nursing confirmed that vaccine training was not in place.
The facility failed to provide timely wound care supplies for two residents, leading to delays in essential treatments. One resident's wound vac was not reapplied as scheduled due to a miscommunication in ordering supplies, while another resident did not receive the prescribed wound cleanser because the facility was out of stock. These deficiencies highlight issues in supply management and communication processes.
The facility failed to transcribe a physician order for emergency administration of diazepam for a resident with severe cognitive impairment and a history of seizures. The medication was delivered and signed by nursing staff but was not documented in the resident's medical record, MAR, or TAR.
A resident with dementia, Down syndrome, anxiety, and dysphagia was admitted with a hospital discharge order for a pureed diet. However, the diet order was incorrectly transcribed as mechanical soft with nectar-thickened liquids. The resident received a meal not in accordance with the prescribed diet, resulting in aspiration, hospitalization, and subsequent death from respiratory failure secondary to aspiration pneumonia. The investigation highlighted discrepancies between hospital discharge paperwork and the facility's medical records, as well as lapses in communication and documentation among staff, including LPNs, RNs, the dietary manager, and CNAs.
Lack of Qualified Dietary Manager Following Staff Departure
Penalty
Summary
The facility failed to ensure that a qualified individual was designated to serve as the Dietary Manager after the previous manager left employment in October. According to the facility's own Dietitian policy, if a dietitian is not employed full time, a Director of Food Service Management must be designated and must meet specific certification or educational requirements. However, after the departure of the former Dietary Manager, the Administrator assumed the role without holding any food service certification, as confirmed during staff interviews. The Registered Dietitian at the facility did not work full time but was responsible for menu approval and spreadsheets. The Administrator provided the facility's Dietitian policy, which clearly states the requirement for the Dietary Manager to be certified. This lapse in following policy and regulatory requirements had the potential to affect kitchen sanitation and the quality of food and nutrition services for all 35 residents in the facility.
Failure to Notify Representative of Antipsychotic Dose Increase
Penalty
Summary
A resident was admitted with hallucinations and was prescribed an atypical antipsychotic medication. On review, it was found that the dose of this medication was increased by a psychiatric practitioner. However, there was no documentation in the resident's progress notes or assessments indicating that the resident's representative was notified of this medication dose increase. The facility's policy requires notification of the resident's representative when there is a change in treatment, such as an increase in medication dosage. During an interview, the Administrator confirmed that they could not find evidence that the required notification had been completed.
Food Cooling and Sanitizer Monitoring Deficiencies
Penalty
Summary
Food was not stored and prepared in a sanitary manner, and the facility did not monitor or document food cooling temperatures. During an initial kitchen tour, surveyors observed several cooked items and leftovers in the reach-in cooler, including cheesy eggs and ham, puree sausage, puree eggs, oatmeal, and burgers/hot dogs, with dates ranging from 7/19/25 to 7/21/25. No food cooling log was observed for the pre-cooked and cooled foods. On interview, the Dietary Manager stated the cooling log was kept in a binder, then retrieved the binder and confirmed there were no cooling logs for the foods in the cooler. The Dietary Manager also stated the cheesy and pureed eggs had been consumed by residents that morning and confirmed the foods observed in the cooler were not documented as properly cooled using a food safety cooling method. The facility also did not properly monitor the Quaternary sanitizing solution used to sanitize kitchen prep areas. Surveyors observed a sanitizer bucket at the three-compartment sink and a sanitizer log that included a column for water temperature, but the log did not contain documented PPM or water temperatures. A poster above the sink indicated QUAT Hydrion required 65-75 degree water temperature with PPM at 150-400. The Dietary Manager confirmed staff taped Hydrion Quaternary sanitizer test strips to the log, but did not document the PPM of the sanitizing solution. The Dietary Manager also confirmed the strips did not accurately record the PPM once adhered to the log and that staff did not test or document the water temperature of the sanitizing buckets before testing the PPM as required.
Food Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature for 5 of 16 sampled residents. During interviews, R5, R6, R8, R12, and R30 each stated that meals were served cold, lukewarm, or otherwise not appetizing. R5, who had chronic DVTs, COPD, neuropathy, edema, and anxiety and had intact cognition, reported that food was delivered cold at every meal and that staff were too busy to reheat it. R6, who had dementia, ESRD on dialysis, COPD, and depression and had moderate cognitive impairment, stated food was cold all the time and that butter did not melt. R8, who had type 2 DM, CKD stage 3, anxiety, and depression and had intact cognition, reported room trays contained cold or lukewarm food and that even timely delivery did not result in appetizing temperatures. R12, who had type 2 DM, cellulitis, and a stage 4 pressure injury and had intact cognition, stated food was not always hot and did not taste good at times due to the temperature. R30, who had osteomyelitis, dysphagia, PTSD, and a cervical ligament sprain and had intact cognition, stated food for all meals arrived cold. During meal service observation, a test tray was requested and later temped while room trays were being delivered. The observed lunch temperatures were roast beef at 124 degrees Fahrenheit, peas at 127 degrees Fahrenheit, and mashed potatoes at 123 degrees Fahrenheit. The Dietary Manager stated staff had received resident complaints about food temperatures, that the facility had two meal service carts and previously had a third, and that there were recent food temperature concerns from residents. The Dietary Manager also did not know whether the plate warmer worked correctly or whether it had been plugged in during meal service. When the plate warmer was checked in the kitchen, it was not plugged in, and when staff plugged it in, the light did not ignite. The Dietary Manager stated the plate warmer had been fixed a while ago and might need replacement, and that the steam table had recently been replaced due to resident complaints about cold food.
Failure to Document Resident Participation in Care Planning
Penalty
Summary
The facility did not ensure that residents were given the right to participate in the development and implementation of their person-centered plan of care. Based on staff and resident interviews and record review, 3 of 16 sampled residents, R5, R7, and R6, did not have documentation of care conferences in their medical records. The facility’s Care Plan Conference policy states the interdisciplinary team, with the resident and/or resident representative, will develop the plan of care based on the comprehensive assessment, and that the facility must encourage participation in care planning and document the conference in the progress notes. R5 was admitted in December 2024, and the medical record did not contain documentation of any care conferences. R5 stated the facility did not communicate regarding discharge planning or the plan of care and that no care conference had occurred since admission. R7 was admitted in August 2024, and the medical record also lacked documentation of any care conferences; R7 stated no care conference had occurred since admission. R6 was admitted in November 2024, and the medical record did not contain documentation of any care conferences; R6 stated the facility did not communicate with R6 or the POA and was not aware of any care conferences. The SSD-M stated R5 had a care conference upon admission, R7 had a care conference upon admission, and R6 had two care conferences, but documentation could not be found for any of them. The SSD-M and DON-B stated care conferences should be completed quarterly.
Failure to Obtain or Offer POAHC Documentation
Penalty
Summary
The facility did not ensure that one resident, R28, was offered the opportunity to create or obtain Power of Attorney for Healthcare (POAHC) paperwork. R28 was admitted to the facility on [DATE], and the resident’s medical record did not contain POAHC documentation or a POAHC refusal document when reviewed by the surveyor on 7/21/25. The facility’s Advanced Directive policy states that the resident has the right to formulate an advance directive, that the facility will inquire at admission whether the resident has previously executed one, and that if one exists, the facility must obtain a copy for the medical record. During interview on 7/21/25, R28 stated the POAHC document was at home in a safe and that family had access to it. The Social Services Director stated that R28 had told her a copy of an advanced directive was in the safe at home and that family had access to the document. The surveyor also reviewed a documented conversation with a family member from 5/12/25 requesting a copy of the document, but the medical record did not show any further documented attempts to contact the family member to obtain the POAHC document. The Director of Nursing stated staff are expected to either obtain a copy of a resident’s POAHC document or offer to create a new one.
Dirty resident room and overflowing trash left unaddressed
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident with intact cognition who was his or her own decision maker. The resident had diagnoses including a stage 2 sacral pressure ulcer, paraplegia, an infection and inflammatory reaction related to an indwelling urethral catheter, and a stage 3 pressure ulcer of the right buttock. During observation, the resident reported concerns that the room was dirty and the garbage was overflowing, and stated housekeeping had not been in to clean the room or remove trash in a few days. The surveyor observed clothing, linens, and other items stacked on the heating and cooling register, along with dirt, dust, food debris, a cotton swab used to clean wounds, and a lancet top on the floor. The garbage can was nearly full and contained used PPE and food. The same conditions were observed later that day and again the next day, with the floor still dirty, the garbage overflowing, and the clothing and linens still stacked on the register. Additional debris, including an orange peel, cotton swabs, lancet tops, dirt, and black debris, remained on the floor, and used PPE was observed in the overflowing garbage can. The resident stated no one had cleaned the room or removed the garbage, and that staff had thrown socks on the floor next to the hamper. The housekeeping staff member interviewed stated there were usually two housekeepers per wing but currently only one per wing, which was not enough, and the maintenance director confirmed resident rooms should be cleaned daily, including removing garbage and cleaning the floor, but acknowledged the room was not cleaned on either day observed.
Incomplete bowel and bladder care plan
Penalty
Summary
The facility failed to develop a comprehensive bowel and bladder care plan for one resident, R7, who was admitted in August 2024 and had diagnoses including schizophrenia, dysphagia, depression, and diabetes. R7's most recent MDS assessment, dated 5/16/25, showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and documented that R7 was occasionally incontinent of bladder and did not have a toileting program. Review of the comprehensive care plan updated on 5/16/25 showed that it did not include problems, goals, or interventions related to incontinence. CNA charting over the prior 30 days showed R7 was incontinent 4 out of 73 occurrences, all during the night shift. During interview, CNA-J stated R7 was continent at all times and independent with toileting and was not aware of the nighttime incontinence. The DON verified that the care plan did not include urinary incontinence and stated toileting/incontinence status should be included in a resident's comprehensive care plan.
Failure to Keep Resident Bed in Lowest Position After Fall
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for one resident, R25, after a fall on 5/2/25. R25 had diagnoses including sequelae following cerebrovascular disease, dysphagia, hemiplegia, and hemiparesis, and the MDS dated 5/15/25 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The resident also had an activated POAHC. A facility investigation stated staff found R25 on the floor between the bed and window at 4:00 PM with a laceration on the top of the head, and the resident could not recall what was being attempted at the time of the fall. The investigation indicated the fall occurred because R25 was exhibiting terminal restlessness. After the fall, an intervention was added to R25's care plan requiring the bed to be in the lowest position, and the care plan initiated on 5/2/25 included that intervention. However, on 7/22/25 at 7:44 AM the surveyor observed R25 in bed with the bed in the highest position. An LPN reviewed the care plan and verified the bed should have been in the lowest position, then lowered the bed and removed the handheld control. Later that day, the surveyor again observed R25 in bed with the bed in a medium height position, and a CNA verified the bed was not in the lowest position and lowered it.
Improper Catheter Bag Placement
Penalty
Summary
The facility did not provide appropriate catheter care for two residents with indwelling catheters when their drainage bags were observed on the floor. R31, who had diagnoses including paraplegia, neurogenic bladder, pressure ulcers, and a recent infection and inflammatory reaction due to an indwelling urethral catheter, had recently been treated for a UTI after an ER visit for cognitive change, weakness, and cloudy urine. On observation, R31’s uncovered catheter bag was hanging from the side of the bed and in contact with the floor, and R31 stated the bag should not be on the floor and that the dignity bag and keeping the catheter bag off the floor helped with infection prevention. A CNA acknowledged the bag should not be on the floor and rehung it, but did not place it in a dignity bag. Later observations showed R31’s catheter bag hung facing the open door and hallway without a dignity bag, and R31 stated the bag should be covered and moved away from that side. R25, who had diagnoses including sequelae following cerebrovascular disease, UTI, dysphagia, hemiplegia, and hemiparesis, had severe cognitive impairment with a BIMS score of 0 and an activated POAHC. During observation, R25’s catheter bag was hung from the side of the bed while the bed was in the lowest position, and the bag was on the floor. A CNA verified the bag was on the floor and stated the bag had not been noticed when the bed was lowered. The DON stated staff should adjust catheter bags so they do not touch the floor. The facility policy and CDC guidance both indicated drainage bags should be kept below the bladder and not rested on the floor.
Failure to Verify Feeding Tube Placement Before Enteral Medication and Feeding
Penalty
Summary
The facility did not ensure appropriate care for two residents who received enteral feeding via PEG or gastrostomy tube. R35, who had diagnoses including Parkinsonism, cerebral infarction, systemic inflammatory response, muscle wasting, atrophy, and neurocognitive disorder, was dependent on staff for transfers, hygiene, dressing, feeding, and bathing. During observation, RN-C administered acidophilus and Jevity 1.5 calorie through R35’s PEG tube after flushing the tube, but did not check tube placement or residual before giving the medication and feeding. RN-C stated there were no orders to check placement or residual, although the resident had a long-standing PEG tube. R4, who had diagnoses including dysphagia with cerebral vascular accident, obesity, and type 2 diabetes, had intact cognition with a BIMS score of 15 and received enteral feeding via gastrostomy tube. During observation, LPN-H crushed and prepared R4’s medication, then administered it through the G-tube without checking tube placement first. The surveyor verified with LPN-H that placement should have been checked prior to medication administration, and the resident’s MAR contained an order to check tube placement. The facility’s enteral feeding and medication administration policy required checking proper placement prior to each feeding or medication administration.
Delayed Fentanyl Patch Replacement and Inadequate Pain Management
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with chronic pain. The resident had diagnoses including chronic DVTs in both legs, neuropathy, depression, anxiety, and chronic pain, and the most recent MDS indicated pain was experienced almost constantly and frequently interfered with daily activities and therapies. The care plan identified chronic pain related to bilateral DVTs and included interventions such as repositioning, distraction, heat, and pain medications. The facility’s pain management policy stated staff were to develop and implement a care plan for pain management, proactively address pain, administer pain medications as ordered, and observe for effectiveness. The resident had an order for a Fentanyl patch to be changed every three days, but during observations the patch remained dated 7/17/25 on 7/21/25 and 7/22/25, even though it should have been changed on 7/20/25. The resident stated pain was 8 out of 10, felt achy, had difficulty sleeping, and said staff did not offer non-pharmacological interventions for pain. The DON verified the patch was overdue and stated the facility did not re-order the Fentanyl patch before using the last one on 7/17/25. The resident’s MAR showed PRN oxycodone use and pain typically rated between 5 and 7 out of 10, and a fax was sent to the physician requesting a refill for the patch. On 7/23/25, the patch was observed dated 7/22/25 and the resident reported feeling much better with pain rated at 5 out of 10.
Failure to Follow Droplet Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when transmission-based precautions were not followed for a resident placed on droplet precautions. The resident had diagnoses including sepsis, pneumonia, and a urinary tract infection due to E-coli, along with COPD, a stage 1 pressure injury, and paranoid schizophrenia. The resident's admission MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognition, and the resident had an activated decision maker for health care decisions. The care plan directed staff to educate the resident/family on precaution policies and to follow standard precautions and transmission precautions when appropriate. Surveyors observed multiple instances of staff entering the resident's room without the required PPE. A CNA entered the room with an oxygen tank and closed the door without donning PPE, and the CNA stated a mask or PPE was not needed unless providing cares or coming into contact with bodily fluids. Housekeeping staff later changed the resident's bed linens without wearing gloves or a mask while the resident was in the room. The DON confirmed the resident was on droplet precautions for pneumonia, UTI, and sepsis, and verified staff should wear a mask when entering the room and that the observed practice was not in accordance with facility policy.
Lack of Regular Pest Control and Evidence of Insects in Resident Room
Penalty
Summary
The facility did not ensure it had a regular pest control program to prevent or address mice, insects, or other pests. During observation and interview, a resident with diagnoses including DVT/PE secondary to factor V Leiden mutation on Xarelto, chronic diastolic CHF, COPD, and morbid obesity reported a bug bite on the right hand and stated something bit the hand during the night, causing immediate swelling and pain. The resident also reported seeing fruit flies throughout the building, and the surveyor observed several fruit flies in the resident’s room. Record review showed the resident had a BIMS score of 14 out of 15 and a progress note documented a new bug bite on the right hand with a previous bite that had become infected; the area was slightly swollen, red, and itchy. The Maintenance Director stated the facility had routine pest care mostly for rodents and outside issues but did not keep records of pest control visits and thought the company had been there in May. The pest control company later confirmed it had last provided service in February and had no active service for the facility, and the NHA confirmed the facility did not have a current pest control contract and had not had pest control since February.
Incorrect Wound Vac Application Led to Worsening Pressure Injury
Penalty
Summary
A resident with a stage 4 pressure injury on the right hip and a wound vac was admitted to the facility with additional diagnoses of cellulitis and paraplegia. The resident required assistance from one to two staff for repositioning and had intact cognition. The facility's policy required that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, using interventions based on current standards and provider orders. The resident's wound vac dressing was applied incorrectly by a registered nurse, as the base drape layer was not placed around the wound during the dressing change. This omission led to skin erosion, irritation, and an increase in the size of the wound, as confirmed by the wound nurse practitioner. The wound vac could not be reapplied due to the skin condition, and the resident required a different type of dressing while the skin healed. The resident had previously reported concerns about the wound vac dressing not being done correctly, and the facility's investigation confirmed the error was due to lack of education for the nurse who performed the dressing change. Interviews with staff revealed that the nurse responsible for the incorrect dressing application was not aware of the mistake until informed by the resident and did not receive education or follow-up until several days after the incident. Other nursing staff also indicated they had not received prior education on wound vacs related to the incident. The documentation showed that the wound worsened following the incorrect application, and the resident expressed concerns that the issue was delaying discharge and affecting their emotional well-being.
Failure to Ensure Safe Medication Administration and Storage
Penalty
Summary
Surveyors identified that the facility failed to ensure safe administration and storage of medications for four residents. Multiple medications, including albuterol inhalers, DuoNeb solution, Afrin nasal spray, pain relief ointments, miconazole powder, Dakin's solution, and Adapt stoma powder, were found at the bedsides of these residents. In each case, there was either no physician's order, no completed self-administration of medication assessment, or both, to authorize the residents to self-administer or store these medications at their bedside. For one resident with respiratory failure and moderately impaired cognition, an albuterol inhaler and DuoNeb solution were left at the bedside, and the resident was unsure of their prescribed medications. Although there was a physician's order to keep the inhaler at the bedside, the required self-administration assessment had not been updated to reflect this. Another resident with pneumonia and moderate cognitive impairment had Afrin nasal spray at the bedside without a physician's order or self-administration assessment. Similarly, a resident with lymphedema and moderate cognitive impairment had an albuterol inhaler at the bedside without the necessary documentation. A fourth resident, who had intact cognition and multiple diagnoses including spinal cord dysfunction and a pressure ulcer, had several topical medications at the bedside. There was no physician's order or self-administration assessment for these medications. In all cases, the Director of Nursing confirmed that the required assessments and orders were missing, and that medications should not have been left at the bedside without proper authorization and documentation.
Environmental Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple environmental deficiencies during their inspection of the facility. The garbage dumpster in the rear parking lot was repeatedly found open on top and in the back, with discarded furniture left nearby. Staff were seen disposing of waste in the dumpster without closing the lid, in violation of the 2022 FDA Food Code, which requires outdoor refuse receptacles to be kept covered with tight-fitting lids or doors. These conditions were noted on several occasions, indicating a pattern of noncompliance with sanitation and safety standards for waste management. Additionally, the facility's main entrance presented several hazards. The concrete outside the entrance was uneven, cracked, and heaving, with measured gaps and rises as large as 5.5 inches. Floor tiles in the walkway between the entrance doors were lifted and cracked. These issues were confirmed by both the maintenance staff and the DON during walkthroughs, with maintenance staff acknowledging that repairs had been discussed but not yet planned or completed. No complaints or incidents related to these hazards were reported by the DON at the time of the survey.
Failure to Obtain Informed Consent Prior to Administering Psychotropic Medications
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and an activated Power of Attorney for Healthcare (POAHC) was administered multiple psychotropic medications without obtaining informed consent prior to the start of the medications. The facility's policy required that informed consent forms be completed and education provided to the resident or their representative before administering such medications. However, the resident's medical record showed that Seroquel, melatonin, and BuSpar were started before the consent forms were signed, and there was no documentation that verbal consent was obtained prior to administration. Additionally, citalopram was started before the consent form was signed, and lorazepam was administered without any informed consent form on file. The resident in question had diagnoses including encephalopathy, nervous system degeneration due to alcohol, alcohol dependence, a history of stroke, and anxiety disorder, with a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The Director of Nursing confirmed during interview that informed consent should have been obtained prior to starting these medications, but this process was not followed as required by facility policy.
Failure to Investigate and Document Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident's missing blue jacket valued at $75. The resident reported the missing item after discharge, prompting the facility to initiate an investigation, notify the police, and file a report with the State Agency. Despite these actions, staff interviews revealed that no one recalled seeing the resident with the blue jacket, and a search for the item was unsuccessful. The investigation was hindered by the absence of a completed personal inventory form upon the resident's admission, making it impossible to confirm whether the jacket was present at that time. Additionally, the facility did not provide staff education on the misappropriation of resident property or on documenting residents' personal property upon admission, even though such education was listed as an immediate and ongoing intervention in the facility's investigation. The facility's own policy required prompt reporting, documentation, and investigation of missing belongings, but there was no evidence that staff had been educated on these procedures in relation to this incident.
Failure to Provide Timely ADL Assistance According to Resident Preferences
Penalty
Summary
Staff failed to provide timely assistance with activities of daily living (ADLs) according to the preferences of a resident who was dependent on staff for oral care, pericare, and personal hygiene. The resident, who had diagnoses including paraplegia, pressure ulcers, colostomy, and urostomy, was cognitively intact and had clearly communicated a preference to receive morning care around 10:00 AM. Despite this, documentation and interviews revealed that the resident received assistance with ADLs during the morning shift only 26% of the time over a one-month period. The resident repeatedly used the call light and requested care, but staff often delayed assistance until the PM shift, leaving the resident without timely hygiene and care as needed. The facility's policy required timely and consistent assistance with personal hygiene and prompt response to call lights, but staff did not consistently follow these protocols for this resident. The resident filed a grievance regarding the lack of timely care, and although the facility indicated the issue was resolved and staff were educated, the resident reported that the problem persisted. Interviews and record reviews confirmed that the resident continued to experience delays in receiving care, including oral hygiene and changes of incontinence pads, particularly during the morning hours as per the resident's stated preference.
Missed Weekly PICC Line Dressing Change
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate care and treatment for a resident with a peripherally inserted central catheter (PICC) line, as ordered and in accordance with facility policy. The facility's policy required weekly PICC line dressing changes and additional changes if the dressing became soiled, loose, or wet. The resident, who had diagnoses including sepsis, osteomyelitis, and type 2 diabetes, was cognitively intact and had clear orders for weekly dressing changes and monitoring of the PICC line site. Documentation showed that dressing changes were completed on 5/5, 5/12, and 6/3, with a PRN change on 5/27, but there was no record of a dressing change during the week of 5/19 as required. On 5/21, a clinic RN observed that the resident's PICC line dressing was dirty and peeling on three corners, prompting the RN to change the dressing and notify facility staff. The Director of Nursing confirmed that the required weekly dressing change was missed by facility staff during that week, and the dressing was instead changed at the clinic. This lapse in following the prescribed schedule and policy for PICC line care constituted the deficiency identified by surveyors.
Failure to Provide Proper BiPAP Equipment Care
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory diagnoses, including heart failure, asthma, obstructive sleep apnea, COPD, and chronic respiratory failure, did not receive proper respiratory care as required by facility policy. The facility's policy specified that BiPAP/CPAP masks, tubing, and humidifiers should be cleaned weekly, and humidifier water should be changed daily. However, the resident reported that the BiPAP equipment was only cleaned once since admission, and this cleaning was performed by the ADON the previous week. There was no evidence in the medical record of a regular cleaning schedule or documentation of BiPAP or humidifier care. Surveyor observations and staff interviews confirmed the lack of documentation and adherence to the cleaning schedule for the resident's BiPAP machine and equipment. The DON acknowledged that the resident's medical record did not contain any documentation of BiPAP or humidifier maintenance, indicating that the necessary respiratory care and services were not provided in accordance with facility policy.
Failure to Provide Mechanical Soft Diet as Ordered
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a mechanical soft diet, due to a diagnosis of dysphagia oropharyngeal phase, was not provided food in the required texture. The resident's medical record indicated the need for a mechanical soft diet, which is defined as minced and moist food that does not require biting and only minimal chewing, with pieces no larger than 4 millimeters. The facility's diet orders and procedures specify that therapeutic diets must be prescribed and communicated to the dietary department, and that food should be prepared according to these orders. During a lunch service observation, staff were seen preparing mechanical soft roast beef by blending regular texture roast beef. However, the staff member responsible for plating the meal placed a regular texture serving of roast beef on the resident's tray, despite the meal ticket clearly indicating a mechanical soft diet. The tray with the incorrect food texture was delivered to the resident. The Dietary Manager confirmed that the resident was not provided the correct diet as ordered, verifying that the roast beef served was not in the mechanical soft form required for the resident's condition.
Failure to Document and Investigate Resident Grievance
Penalty
Summary
The facility failed to document, investigate, or resolve a grievance raised by the legal representative of a resident who had a respite stay. The resident, who had severe cognitive impairment and an activated Power of Attorney for Healthcare, was discharged after a stay during which concerns were later expressed by the legal representative. These concerns included issues with hygiene, showers, blood sugar monitoring, and financial bills. The facility's policy requires that all grievances be documented, investigated, and resolved with follow-up provided to the complainant. Despite the legal representative expressing these concerns to the Social Worker after discharge, no grievance was filed, and there was no documentation or evidence of investigation or resolution in the facility's grievance log. The Social Worker acknowledged receiving the concerns and relaying them to the DON, but did not file a grievance or follow up with the legal representative. The DON did not recall receiving the concerns and did not initiate any grievance process. The Nursing Home Administrator confirmed that a grievance should have been filed but was not.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, which has the potential to affect all 46 residents. The Dietary Manager (DM-C) was promoted from a Dietary Aide position in April 2024 without completing an approved dietary manager or food service manager certification course. DM-C had no prior experience or training before employment at the facility and was working towards certification with the assistance of the Nursing Home Administrator (NHA-A) and Regional Dietitian (RD-E). However, DM-C had to file for an extension due to not completing the course within the required timeframe and experiencing a mentor change during the course. RD-E, who was not onsite full-time, confirmed their limited availability, and NHA-A acknowledged the need for an extension for DM-C's course completion.
Failure to Adhere to Dietary Modifications for Residents
Penalty
Summary
The facility failed to meet the nutritional needs of five residents who were on carbohydrate-controlled diets. These residents were served regular diet portions of dessert, contrary to their prescribed dietary modifications. The facility's dietary staff did not adhere to the portion sizes specified for different diet types, as evidenced by the use of incorrect scoop sizes during meal service. The dietary manager acknowledged that there was no extended menu or form indicating the appropriate serving sizes, leading to uniform portion sizes being served to all residents, regardless of their dietary requirements. The deficiency was further highlighted by the dietary manager's admission that desserts were provided in full portions to residents on carbohydrate-controlled diets if they requested them, despite the lack of modifications on their meal tickets. A registered dietitian confirmed that the dietary staff were not following the diet orders, as the appropriate scoop sizes were not used, and residents on carbohydrate-controlled diets should have received half-portions of dessert. This oversight was observed during a kitchen inspection and through interviews with staff and residents, revealing a systemic issue in the facility's dietary service.
Failure to Complete Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed according to its Fall Management policy after a resident experienced falls. The policy, revised in July 2020, mandates that neurological checks be conducted and documented following a fall if the resident hit their head or if it is unclear whether they did, such as in unwitnessed falls. The checks should follow a specific schedule outlined in the facility's Neuro Check Assessment Form. However, for one resident, identified as R1, the staff did not adhere to this protocol after falls on two occasions. R1, who was admitted with diagnoses including sepsis, type 2 diabetes, and hypertension, had a moderate cognitive impairment as indicated by a Brief Interview for Mental Status score of 11 out of 15. The resident's medical record showed a risk for falls care plan and an actual fall with no injury care plan. Despite these measures, R1 experienced unwitnessed falls on two separate dates. Upon review, it was found that staff missed 12 out of 22 required neurological checks after the first fall and 2 out of 22 checks after the second fall. The Director of Nursing confirmed the incompleteness of these checks, acknowledging the failure to follow the facility's policy.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 40 residents. The facility lacked a system for monitoring cooked food temperatures and hot/cold holding temperatures. During the survey, it was observed that the facility's Food Temperature Record policy was not followed, as temperatures for cooked and held foods were not documented. The surveyor noted that the food temperature logs for several meals in June were blank, indicating a failure to record necessary temperatures. The Dietary Manager confirmed that food temperatures should be obtained and documented to ensure foods are thoroughly cooked and held at safe temperatures. Additionally, staff did not practice safe food handling by failing to wear hair and beard restraints while cooking and serving food. The facility's Hair Restraints policy requires hair restraints to be worn by anyone in the kitchen to prevent hair from contaminating food. However, the surveyor observed staff members in the kitchen without appropriate hair or beard restraints. One staff member, identified as CK-E, was seen preparing food without a beard restraint, despite having a full beard and mustache. The Dietary Manager acknowledged that staff should wear hair nets and beard restraints and confirmed that CK-E was not wearing a beard net as required. The lack of adherence to food safety protocols, including temperature monitoring and the use of hair and beard restraints, represents a significant deficiency in the facility's food service operations. These practices are essential to prevent contamination and ensure the safety and quality of food served to residents. The failure to consistently document food temperatures and enforce the use of hair restraints indicates a lapse in the facility's compliance with established food safety standards.
Unqualified Dietary Manager
Penalty
Summary
The facility did not ensure the individual designated as the food and nutritional services director met the minimum qualifications for the role. The Dietary Manager (DM)-G, who was promoted from a Dietary Aide position a little over a month ago, had not completed an approved dietary manager or food service manager certification course or other related education. DM-G had no prior experience or training and was not enrolled in a certification program at the time of the survey. The Nursing Home Administrator (NHA)-A was aware of DM-G's lack of certification and was working with the Regional Dietitian (RD)-P to set up training, but this had not been initiated until the surveyor's visit.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a sanitary manner, potentially affecting 47 of 48 residents. Staff failed to monitor or document food cooling temperatures, and the handwashing sink did not reach the required minimum temperature for proper hand hygiene. Additionally, a can opener was found with dried debris and food residue on the blade, and visibly soiled oven mitts were left on top of condiment containers. Chemicals used for cleaning were stored near food containers and food preparation areas, and on two occasions, resident room trays were delivered uncovered on top of the food cart. Staff also did not test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Seven food items were not dated when opened, not discarded when beyond the use-by/expiration date, and/or not stored appropriately. The FDA Food Code 2022 specifies that cooked time/temperature control for safety food must be cooled within specific time frames and using certain methods. However, the facility did not have a process to monitor cooling, as confirmed by the Dietary Manager (DM). The handwashing sink in the kitchen did not reach the required temperature for proper hand hygiene, and the Dietary Manager acknowledged this issue. The can opener was found with dried debris and food residue, and the Dietary Manager verified that it was only cleaned monthly, which could contribute to cross-contamination. Soiled oven mitts were observed on top of condiment containers, and the Dietary Manager acknowledged that this could lead to cross-contamination. Cleaning chemicals were stored near food preparation areas, contrary to the facility's policy. Resident room trays were delivered uncovered, and the Dietary Manager confirmed that food items should be covered when leaving the kitchen. The facility did not have a process to ensure proper chemical sanitization, and staff were not trained on chemical sanitization. Several food items were found unlabeled, undated, or beyond their expiration dates, and the Dietary Manager immediately discarded these items.
Infection Preventionist Training Deficiency
Penalty
Summary
The facility did not ensure that the designated Infection Preventionist (IP), who was the Director of Nursing (DON), completed the required specialized training in infection prevention and control. The DON completed the Centers for Disease Control and Prevention (CDC) training modules but did not pass the certification test and missed the deadline to retake it. The facility had hired an Assistant Director of Nursing (ADON) to eventually take over the IP role, but the ADON had not yet started the position. This deficiency had the potential to affect all 48 residents residing in the facility.
Failure to Offer POAHC Paperwork to Resident
Penalty
Summary
The facility did not ensure that a resident (R25) was offered the opportunity to create or obtain Power of Attorney for Health Care (POAHC) paperwork. R25 was admitted to the facility, and the facility failed to obtain R25's POAHC document or offer R25 the chance to fill out a new document until several months later. The facility's Advanced Directive policy and procedure require that the facility inquire at the time of admission whether the resident has previously executed an advance directive and obtain a copy if it exists. However, R25's medical record did not contain POAHC documentation upon review by the surveyor. On the day of the surveyor's review, R25 indicated that they had a POAHC document from 2004 at home and did not wish to fill out another one. The surveyor found that the refusal document was signed by R25 on the same day as the interview, despite being dated earlier. Interviews with the Social Services Assistant (SSA-C) and Social Services Director (SSD-D) confirmed that the refusal document was backdated, and R25's signature was obtained on the day of the surveyor's visit, not on the earlier date indicated on the document.
Failure to Notify POAHC of Resident's Fall
Penalty
Summary
The facility did not notify a Power of Attorney for Healthcare (POAHC) when a resident experienced a change in condition following a fall. The resident, who had severe cognitive impairment and was at high risk for falls, fell in their room on 5/1/24. The fall incident report indicated that the resident's physician and the Director of Nursing were notified, but there was no documentation that the POAHC was informed. The POAHC only learned of the fall during a visit to the resident and confirmed the incident with the staff. The facility's Fall Management policy requires that the nurse communicate any falls to the attending physician and the resident's representative and document this notification. However, the nurse responsible for notifying the POAHC did not do so. The Nursing Home Administrator confirmed that the POAHC was not notified and acknowledged that this was against the facility's policy. The deficiency was identified during a survey conducted from 5/6/24 to 5/8/24.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility did not ensure that two residents received a written transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. Resident R145 was transferred to the hospital and did not receive a written transfer notice. The medical record indicated that R145 had intact cognition and was transferred due to a fall. Staff interviews revealed that the LPNs were unaware of the requirement for a written transfer notice, and the Director of Nursing confirmed that R145 did not receive the required notice. Similarly, Resident R32 was transferred to the hospital and neither the resident nor the resident's Power of Attorney for Healthcare (POAHC) received a written transfer notice. R32 had intact cognition and was hospitalized due to exacerbation of asthma and heart failure. Staff interviews indicated that the LPNs were not aware of the transfer notice requirement, and the Nursing Home Administrator confirmed the lack of documentation for the written transfer notice. The facility's Bedhold Notification policy included a sample letter for transfer notices, but it was not utilized in these cases.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility did not ensure that two residents received written notification of the bed hold policy when they were transferred to the hospital. Resident 145, who had diagnoses including heart failure and obstructive sleep apnea, was transferred to the hospital following a fall. The medical record review and staff interviews revealed that Resident 145 did not receive a written copy of the bed hold policy, although the facility's policy requires it. Licensed Practical Nurses interviewed were either unsure of the process or indicated that the Social Worker was responsible for obtaining the resident's signature on the bed hold policy, which did not occur in this case. The Director of Nursing confirmed the oversight. Similarly, Resident 32, who had diagnoses including neoplasm of uncertain behavior of the brain and acute respiratory failure, was hospitalized and did not receive a written copy of the bed hold policy. The Nursing Home Administrator confirmed that there was no documentation indicating that the bed hold policy was provided or reviewed with Resident 32 or their Power of Attorney for Healthcare. Both instances indicate a failure to follow the facility's Bedhold Notification policy, dated March 2021, which mandates providing written notice to residents or their representatives regarding bed hold rights upon hospital transfer.
Failure to Complete Comprehensive Assessment After Significant Change
Penalty
Summary
The facility did not ensure a comprehensive assessment was completed after a significant change in condition for one resident (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24, but the facility did not complete a comprehensive assessment for this significant change in condition. According to the CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, comprehensive assessments are required upon admission, annually, and when a significant change in a resident's status occurs. On 5/6/24, a surveyor reviewed R8's medical record and found no comprehensive MDS assessment for the significant change when R8 started Hospice services. The Nursing Home Administrator confirmed on 5/8/24 that the facility did not complete the required significant change assessment for R8.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) that included essential healthcare information for a resident (R149) within 48 hours of admission. Specifically, the BCP did not include information related to R149's dialysis schedule, dietary requirements, and smoking status. R149 was admitted with severe protein-calorie malnutrition, end-stage renal disease, renal dialysis, nicotine dependence, and dysphagia. Despite having a BIMS score indicating intact cognition, the BCP lacked critical details necessary for R149's care, such as a low potassium diet with mechanical soft texture and thin liquids, dialysis orders for specific days, and the need for assistance while smoking as indicated by a smoking assessment. Interviews with facility staff, including two LPNs and the Director of Nursing (DON), revealed inconsistencies and a lack of awareness regarding R149's smoking status and care needs. The DON confirmed that the BCP should have included interventions for assistance with smoking, as well as dietary and dialysis information. The failure to incorporate these essential elements into the BCP represents a significant oversight in the resident's initial care planning process, as outlined by the facility's own policies and procedures.
Failure to Develop and Implement Hospice Care Plan
Penalty
Summary
The facility did not ensure a comprehensive care plan was developed and implemented for a resident (R8) who started Hospice services. R8, admitted with diagnoses including dementia, diabetes, and coronary heart disease, began Hospice care on 3/13/24. However, upon review on 5/6/24, it was found that R8 did not have a care plan or an order for Hospice care. Interviews with the Power of Attorney for Healthcare, the Director of Nursing, and the Regional Consultant confirmed that the necessary Hospice care plan and physician's order were not in place until 5/8/24, despite the resident starting Hospice care in March. The Nursing Home Administrator also verified that the Hospice order was only entered into R8's medical record on 5/8/24.
Failure to Complete Post-Fall Neurological Checks
Penalty
Summary
The facility did not provide adequate monitoring post-fall for one resident (R34) of two residents reviewed for falls. The facility's Fall Management policy requires neurological checks to be completed at specific intervals following an unwitnessed fall. However, after R34's unwitnessed falls on 9/21/23 and 10/21/23, the required neurological checks were not fully completed. For the fall on 9/21/23, neurochecks were only completed for the first hour and a half, and for the fall on 10/21/23, neurochecks were only completed for twenty-four hours post-fall, instead of the required 72 hours. This failure to follow the policy was confirmed by the Director of Nursing (DON)-B during an interview with the surveyor on 5/8/24. R34 was admitted to the facility with diagnoses including Parkinsonism, muscle wasting and atrophy, unspecified severe protein-calorie malnutrition, and altered mental status. R34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severely impaired cognition, and was at high risk for falls due to confusion. Despite these conditions, the facility did not adhere to its own policy for post-fall neurological monitoring, which is critical for detecting potential head injuries. The DON confirmed that the staff did not complete the neurochecks as required by the facility's policy.
Failure to Clean Respiratory Equipment
Penalty
Summary
The facility did not ensure that respiratory equipment was routinely cleaned for two residents, R145 and R156. R145 had diagnoses including heart failure, morbid obesity with alveolar hypoventilation, and obstructive sleep apnea. Despite having an order to change oxygen tubing weekly, R145's medical record did not contain an order or care plan for CPAP cleaning. Observations revealed that R145's oxygen tubing was not labeled with the last change date, and staff confirmed that the CPAP equipment had not been cleaned as required. Interviews with LPNs and the Director of Nursing (DON) confirmed the absence of necessary orders and care plans for CPAP and oxygen equipment cleaning in R145's medical record. Similarly, R156, who had diagnoses including heart failure, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia, did not have an order or care plan intervention to clean CPAP equipment upon admission. R156 reported that the CPAP equipment had not been cleaned since admission, and the oxygen tubing was not labeled with the last change date. Staff interviews confirmed that the necessary orders for CPAP cleaning and oxygen tubing changes were not entered upon admission. The DON verified that the required orders and care plans were missing from R156's medical record and acknowledged that scheduled cleanings should have been care planned upon admission.
Failure to Ensure Communication and Documentation for Dialysis Care
Penalty
Summary
The facility did not ensure ongoing communication and collaboration with the dialysis center for a resident who required daily peritoneal dialysis. The resident, who had diagnoses including end-stage renal disease, diabetes mellitus, obesity, and congestive heart failure, had an order for daily weights to be obtained. However, the resident's daily weight was not recorded on 8 out of 38 days. Additionally, the facility failed to notify the physician or dialysis center when the resident's weight exceeded the specified parameters, as required by the physician's orders. This lack of communication and documentation was confirmed through staff interviews and record reviews. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) interviews revealed that the staff were aware of the importance of daily weights for determining dialysis settings but failed to consistently obtain and document these weights. The LPN admitted that the staff might have forgotten to document the missing weights and were unclear about the meaning of the estimated dry weight (EDW). The DON acknowledged the missing weights and the lack of documented communication with the dialysis clinic regarding the resident's increased weight. The facility's failure to adhere to its peritoneal dialysis policy and physician orders led to this deficiency.
Failure to Ensure Monthly Drug Regimen Review and Timely Action on Pharmacy Recommendations
Penalty
Summary
The facility did not ensure that a licensed pharmacist performed a monthly drug regimen review (MRR) for a resident (R32) over several months, specifically September 2023, October 2023, November 2023, December 2023, January 2024, and March 2024. Additionally, pharmacy recommendations made in April 2024 were not reviewed or acted upon by R32's physician. R32, who had intact cognition and an activated Power of Attorney for Healthcare, was prescribed doxycycline for hidradenitis suppurativa and had a potential drug interaction with Milk of Magnesia that was not addressed in a timely manner. The surveyor's review of R32's medical record revealed that the pharmacy's recommendation to adjust the administration timing of doxycycline and Milk of Magnesia was not acted upon until nearly a month later. The Director of Nursing (DON) confirmed that the only documentation for R32's monthly pharmacy MRR was a recommendation report from April 2024 and a consultation report from February 2024, which listed no recommendations. The delay in acting on the pharmacy's recommendations and the lack of monthly MRRs contributed to the deficiency identified by the surveyor.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for two residents. Resident R15 had an order for droplet precautions due to respiratory concerns, but a CNA assisted R15's roommate without wearing PPE. The CNA was unaware of the need for PPE despite the presence of an isolation cart and droplet precautions sign outside the room. Additionally, the Director of Nursing was not aware of the physician-ordered droplet precautions for R15, leading to inconsistent and inadequate infection control practices for the resident with respiratory concerns. In another instance, during wound care for Resident R4, an RN retrieved a flashlight and scissors from beneath their gown without disinfecting the scissors before use. The RN used the contaminated scissors to cut a dressing for R4's wound. Furthermore, both the RN and a CNA failed to properly remove their face masks after completing wound care, potentially spreading contaminants. These actions demonstrate a lack of adherence to infection control protocols, putting residents at risk of infection.
Failure to Administer and Document Influenza B and Pneumococcal Vaccinations
Penalty
Summary
The facility did not ensure that influenza B and pneumococcal vaccinations were reviewed, offered, and administered for three residents (R8, R2, and R4) out of five sampled residents. Specifically, the facility failed to review R8's vaccination history or offer the PCV20 and influenza B vaccines. Similarly, R2's medical record did not indicate that the PCV20 and influenza B vaccines were offered or administered, despite R2 having received a PPSV23 vaccine in the past and refusing a vaccine on a later date. R4's medical record also lacked documentation of being offered or administered the PCV20 vaccine, even though R4 had previously received both PPSV23 and PCV13 vaccines. The Director of Nursing (DON) acknowledged that the facility was not up to date with influenza B and pneumococcal vaccinations. The Regional Consultant (RC) provided vaccination documents and confirmed that the required documents for R8, R2, and R4 were missing. The facility had started a Process Improvement Plan (PIP) to address the issue of resident vaccines not being up to date, missing consents, declinations, and education for past vaccines, and the absence of a resident vaccine binder.
Failure to Document and Implement COVID-19 Vaccination Program
Penalty
Summary
The facility did not ensure medical records contained documentation related to COVID-19 immunization for three residents. Specifically, the medical records for these residents did not indicate whether they were offered, declined, or administered a COVID-19 vaccine. Additionally, the facility failed to implement a COVID-19 immunization program for staff, as confirmed by interviews with staff members and the Director of Nursing. The facility's policy required education and offering of the COVID-19 vaccine to residents and staff, along with proper documentation, but this was not followed for the sampled residents and staff members. The surveyor's interviews revealed that the facility did not provide staff with information on COVID-19 or offer COVID-19 immunizations. The Director of Nursing admitted that COVID-19 vaccine training for staff and residents was not yet in place. The Regional Consultant provided documentation indicating that the facility lacked the required vaccination records for the three residents. The facility had started a Process Improvement Plan to address the issue of missing consents, declinations, and education for past vaccines, but this was not yet implemented at the time of the survey.
Failure to Provide Timely Wound Care Supplies
Penalty
Summary
The facility failed to ensure that two residents received the necessary care and services to promote healing of their pressure injuries. Resident 33 had a wound vac that was supposed to be reapplied on specific dates, but due to a failure in timely ordering of supplies, the wound vac was not reapplied until much later. This delay was caused by a miscommunication and lack of follow-up after the previous Director of Nursing left the facility. The resident expressed concern about the extended period without the wound vac, and staff interviews confirmed the delay in ordering supplies. Resident 4 had a pressure injury on the coccyx and an order to cleanse the wound with Vanshe wound cleanser. During an observation, it was noted that the staff did not use the prescribed cleanser because the facility was out of stock. The nurse responsible for the wound care was unsure how long the facility had been out of the cleanser and whether it had been reordered. Further investigation revealed that the Director of Nursing had not followed up adequately to ensure the order was placed and received. Both cases highlight a failure in the facility's supply management and communication processes, leading to delays in essential wound care treatments. The facility's Dressing Change policy, which aims to prevent wound contamination and promote healing, was not adhered to, resulting in deficiencies in the care provided to these residents.
Failure to Transcribe Physician Order for Emergency Medication
Penalty
Summary
The facility did not ensure a physician order was transcribed for one resident (R4) out of five sampled residents. R4's hospital discharge paperwork, dated 4/4/24, contained an order for emergency administration of diazepam during a seizure lasting longer than three minutes. However, this order was not transcribed into R4's medical record, nor was it included in the medication administration record (MAR) or treatment administration record (TAR). The pharmacy delivered the medication on 4/4/24, and it was signed by nursing staff, but the order was not documented in the resident's medical record. R4 had severe cognitive impairment, as indicated by a BIMS score of 0 out of 10 on the Minimum Data Set (MDS) assessment dated 4/14/24. R4 had a history of quadriplegia and generalized idiopathic epilepsy and epileptic syndromes. On 3/31/24, R4 experienced a seizure lasting longer than three minutes and was sent to the emergency room and admitted due to an infection. Despite the clear need for the diazepam order, the Director of Nursing (DON) confirmed that the order was not transcribed, which meant that if R4 had another seizure lasting longer than three minutes, the medication would not be administered.
Dietary Documentation and Communication Errors Leading to Resident Harm
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form designed to meet individual needs for a resident (R1) who had an order for a mechanically-altered diet. R1, who had diagnoses including dementia, Down syndrome, anxiety, and dysphagia, was admitted with a hospital discharge order for a pureed diet. However, staff transcribed R1's diet order incorrectly as mechanical soft with nectar-thickened liquids. On 3/13/24, R1 received the wrong meal tray with food not in accordance with the diet order, leading to aspiration, hospitalization, and ultimately, passing away on 3/23/24 from respiratory failure secondary to aspiration pneumonia. The investigation revealed discrepancies between R1's hospital discharge paperwork indicating a pureed diet and the facility's medical record showing a regular diet with mechanical soft texture and nectar-thickened liquids. Despite indications of R1's need for a pureed diet, the facility's dietary slip and medical record reflected a mechanical soft diet order. The failure to accurately document and serve the appropriate diet for R1 resulted in a critical incident that led to serious harm and ultimately, the resident's death. Staff interviews with the LPN, RN, dietary manager, and CNA revealed lapses in communication and documentation regarding R1's diet needs. LPN-E, who was informed of R1's pureed diet order, noted discrepancies in the diet served to R1 and promptly alerted the on-call NP upon observing adverse reactions. RN-D, responsible for entering diet orders, could not recall the source of the mechanical soft diet order and lacked clarity on the verification process for admission orders.
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 114 citations issued within 25 miles in the last 12 months — including the 4 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) |
|---|---|---|---|---|
| Peabody Manor | 1 mi | ★★★★★ | 0 | 0 |
| Oakridge Gardens Nur Ctr, Inc | 1.4 mi | ★★★★★ | 0 | 0 |
| Edenbrook Of Appleton North | 2.7 mi | ★★★★★ | 3 | 1 |
| Rennes Health And Rehab Center-appleton | 2.8 mi | ★★★★★ | 0 | 0 |
| Brewster Village | 3.2 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Meadowbrook At Appleton.
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.