Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Peabody Manor during CMS and state inspections, most recent first.
The facility did not consistently monitor or document refrigerator and freezer temperatures for all food storage units, including semi-trucks used after the removal of some coolers and freezers. Staff were unclear about which units required temperature checks, and temperature logs were incomplete, with no entries after a certain date. This failure had the potential to affect all residents, as perishable food may not have been stored safely.
A resident with a history of COPD and other chronic conditions did not receive necessary respiratory care, as physician orders for oxygen therapy were not consistently followed and the care plan did not address respiratory needs. The resident's active diagnoses list also failed to include COPD, and the facility lacked policies for oxygen administration, as confirmed by the DON.
A resident with a history of falls and specific medical conditions fell during an EZ Stand transfer due to inadequate supervision and an outdated care plan. Despite an initial update requiring two staff for transfers, a CNA transferred the resident alone, resulting in a fracture. The care plan failed to remove outdated instructions, contributing to the incident.
A facility failed to provide a written transfer notice to a resident's guardian and did not notify the Ombudsman when the resident was transferred to the hospital. The resident, with a history of CVA, dysphagia, cognitive impairment, and a GJ tube, was unable to communicate verbally. Although the guardian was notified of the transfer, the facility did not provide the required written notice. Staff interviews revealed inconsistencies in the process of providing and documenting transfer notices.
A resident was transferred to the hospital without their guardian receiving a written bed hold notice, as required by the facility's policy. The resident, who had multiple medical conditions and was unable to communicate verbally, was sent to the ER due to health issues. Staff interviews revealed confusion and inconsistency in the process of providing and documenting the bed hold notice, leading to the deficiency.
A resident with end-stage renal disease did not receive appropriate dialysis care at the facility. The resident lacked a dialysis care plan, and staff failed to perform required pre- and post-dialysis assessments, including monitoring the fistula site. Interviews with the DON and an RN confirmed that the facility's dialysis policy was not being followed.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene protocols during resident care. Staff did not wash or sanitize hands between glove changes for a resident with paraplegia, and a CNA failed to perform hand hygiene during peri-rectal care for a resident with a suprapubic catheter. Additionally, a nurse did not don a gown while administering tube feeding to a resident on enhanced barrier precautions.
An altercation between two residents resulted in one resident expressing fear, which was not reported to the NHA or SA in a timely manner, as required by the facility's policy. The incident involved verbal aggression and physical actions by one resident towards another, but the staff failed to immediately report the fear expressed by the affected resident, leading to a deficiency in the facility's reporting protocol.
The facility did not thoroughly investigate an abuse allegation after a resident-to-resident altercation where one resident expressed fear of another. The incident involved verbal aggression and a physical act, but the investigation lacked interviews with other potential witnesses. Both residents involved had little cognitive impairment and were responsible for their healthcare decisions.
Failure to Monitor and Document Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as required by both the Wisconsin Food Code and the facility's own policies. Surveyors observed that refrigerator and freezer temperatures, including those in semi-trucks used for food storage, were not consistently monitored or documented. The temperature log only accounted for one cooler and one freezer, despite the presence of multiple units, and no temperatures were recorded after a certain date. Staff interviews revealed confusion and lack of direction regarding which units required temperature monitoring, and some staff reported difficulty accessing the semi-truck units to obtain readings. Additionally, there was an incident where a truck malfunctioned, resulting in spoiled food that had to be discarded. The deficiency had the potential to affect all 47 residents in the facility, as perishable food items may not have been stored at safe temperatures. Staff, including the Food Service Specialist and kitchen staff, acknowledged that temperature checks were not being performed as required and were unsure why documentation had ceased after the removal of some coolers and freezers. The Nursing Home Administrator confirmed that all coolers, refrigerators, and freezers should be monitored and recorded daily, but this was not being done in practice.
Failure to Provide Appropriate Respiratory Care and Follow Oxygen Orders
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with a history of chronic respiratory disease. The resident, who had diagnoses including centrilobular emphysema, vascular dementia, atrial fibrillation, and a documented history of COPD, was admitted with ongoing respiratory needs. Despite physician orders specifying oxygen titration up to 6 liters by nasal cannula to maintain oxygen saturation at 90% or greater, documentation showed the resident received oxygen at higher flow rates (8-10 liters/minute) and had persistently low oxygen saturations (as low as 67%). The facility's staff confirmed that the physician's orders were not consistently followed during this period. Additionally, the resident's plan of care did not reflect the use of oxygen therapy or include interventions, goals, or care planning related to respiratory disease, and COPD was not listed among the resident's active diagnoses despite multiple medical records and hospital notes indicating its presence. The Director of Nursing acknowledged these omissions and confirmed that the facility lacked policies related to the administration of oxygen or physician orders, contributing to the failure to provide appropriate respiratory care.
Failure to Ensure Safe Transfer Procedures for Resident
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents for one resident. The resident, identified as R9, experienced a fall during an EZ Stand transfer, which was initially addressed by updating the care plan to require the assistance of two staff members for all such transfers. However, on a subsequent occasion, a Certified Nursing Assistant (CNA) transferred R9 without a second staff member present, resulting in another fall where R9 sustained a right tibial plateau fracture. R9's medical history included conditions such as restless leg syndrome, lymphedema, and primary osteoarthritis of both knees. Despite having a perfect score on the Brief Interview for Mental Status, indicating no cognitive impairment, R9 was vulnerable to falls during transfers. After the initial fall, the facility replaced the EZ Stand slings to ensure proper security, but the care plan was not adequately updated to reflect the new intervention of using a Hoyer lift with two staff members for all transfers. The deficiency was further compounded by the failure to remove outdated instructions from R9's care plan, which still included verbiage about using an air splint for EZ Stand transfers. This oversight contributed to the CNA's non-compliance with the updated care plan, leading to the second fall. The Director of Nursing acknowledged that the care plan should have been revised to eliminate references to the EZ Stand, ensuring that R9 was only transferred using a Hoyer lift.
Failure to Provide Written Transfer Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written transfer notice to a resident's guardian and did not notify the Ombudsman when the resident was transferred to the hospital. The resident, who had a history of cerebrovascular accident, dysphagia, cognitive impairment, and a gastrojejunostomy tube, was unable to communicate verbally and had a guardian for healthcare decisions. On the day of the transfer, the resident was sent to the emergency room due to nausea, vomiting, and low blood pressure, and was diagnosed with hypotension secondary to nausea and vomiting related to hypovolemia. Although the guardian was notified of the hospital transfer, the facility did not provide a written transfer notice as required by their policy. Interviews with facility staff revealed a lack of clarity and consistency in the process of providing and documenting the transfer notice. A registered nurse indicated that if a resident is unable to sign the Bed Hold/Transfer form, verbal consent is obtained from the resident's representative, but there was uncertainty about the procedure if the representative could not sign. The social worker confirmed the absence of a Bed Hold/Transfer form for the resident's hospital transfer and was unsure if such a form was sent with the resident. The social worker also indicated that the responsibility for informing and obtaining a signature from the resident's representative lies with the nursing staff, but there was no clear process to ensure the representative received a written copy of the form.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to the guardian of a resident who was transferred to the hospital. The resident, who had a history of cerebrovascular accident, dysphagia, cognitive impairment, and a gastrojejunostomy tube, was transferred to the emergency room due to nausea, vomiting, and low blood pressure. Although the guardian was notified of the hospital transfer, there was no documentation indicating that a written Bed Hold/Transfer notice was provided. Interviews with facility staff revealed a lack of clarity and consistency in the process of providing and documenting the bed hold notice. The Registered Nurse indicated that if a resident is unable to sign the form, verbal consent is obtained from the family or guardian, but was unsure of the procedure if the representative could not sign. The Social Worker confirmed the absence of a Bed Hold/Transfer form for the resident's transfer and was uncertain about the process for ensuring the guardian received a written copy. This lack of documentation and unclear procedures contributed to the deficiency.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R311, who required such services. R311, diagnosed with end-stage renal disease and dependent on renal dialysis, did not have a dialysis care plan in place. Additionally, the nursing staff did not perform pre- and post-dialysis assessments, nor did they assess and monitor R311's fistula site as required by the facility's policy. The lack of documentation and assessments was confirmed through interviews with the Director of Nursing and a Registered Nurse, who acknowledged that the necessary procedures were not being followed. R311 was admitted to the facility with a diagnosis of end-stage renal disease and required hemodialysis three times a week, along with intravenous antibiotic therapy during dialysis sessions. Despite the resident's cognitive awareness, as indicated by a BIMS score of 14 out of 15, the facility failed to ensure proper communication and documentation regarding dialysis care. The Director of Nursing admitted that there was no paperwork sent with R311 to dialysis appointments, and the nursing staff were not documenting daily assessments of the fistula site, which was a deviation from the established policy.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to hand hygiene protocols during resident care. Specifically, during the care of a resident with paraplegia and other conditions, staff members did not wash or sanitize their hands between glove changes while providing wound, incontinence, and catheter care. This was observed despite the facility's policy requiring hand hygiene before and after glove use. The involved staff acknowledged their failure to follow the protocol, despite being trained in infection control practices. Another incident involved a resident with a suprapubic catheter, where a CNA did not perform hand hygiene between glove changes during peri-rectal care. The CNA admitted to not washing or sanitizing hands, although aware of the requirement to do so. This oversight occurred even though the resident was on enhanced barrier precautions due to their medical condition. Additionally, a nurse failed to don a gown while administering tube feeding to a resident on enhanced barrier precautions. The nurse believed a gown was unnecessary as no bodily fluids were involved, contrary to the facility's policy. The Director of Nursing confirmed that PPE, including gowns, should be used for residents on enhanced barrier precautions during such procedures.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the Nursing Home Administrator (NHA) and the State Agency (SA) in a timely manner. On April 23, 2024, an altercation occurred between two residents, R2 and R3, during which R3 was verbally aggressive and pushed R2's bed. R2 expressed fear of R3 to the staff, but this incident was not immediately reported to the NHA or the SA as required by the facility's Resident Abuse Prevention & Reporting Policy. The policy mandates that any suspicions or allegations of abuse be reported immediately to the Administrator and to the Division of Quality Assurance (DQA) within twenty-four hours. The Director of Nursing (DON) confirmed that the incident should have been reported immediately and acknowledged that the email sent by a nurse to the NHA did not mention R2's expressed fear, which constitutes an allegation of abuse. The medical records of R2 and R3 indicated that both residents had little cognitive impairment and were responsible for their healthcare decisions. However, R2's medical record did not document the incident, and the email communication failed to convey the urgency and seriousness of the situation, leading to a deficiency in the facility's reporting protocol.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents, R2 and R3, following a resident-to-resident altercation. On the date of the incident, R3 was verbally aggressive towards R2 and pushed R2's bed while R2 was sitting on it. R2 reported to a CNA that R3 threw a lighter at them, although it did not make contact. R2 expressed fear of R3, which constitutes an allegation of abuse according to the facility's policy. However, the facility did not conduct a comprehensive investigation as required. The facility's investigation was incomplete as it did not include interviews with other residents or staff who might have witnessed the incident. The Director of Nursing confirmed that a thorough investigation should have included these interviews. The medical records of R2 and R3 indicated that both had little cognitive impairment and were responsible for their healthcare decisions. Despite the incident being reported to the Nursing Home Administrator, the documentation lacked evidence of a full investigation, highlighting a deficiency in the facility's response to the abuse allegation.
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 116 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) |
|---|---|---|---|---|
| Oakridge Gardens Nur Ctr, Inc | 0.6 mi | ★★★★★ | 0 | 0 |
| Meadowbrook At Appleton | 1 mi | ★★★★★ | 2 | 0 |
| Brewster Village | 3.3 mi | ★★★★★ | 13 | 0 |
| Edenbrook Of Appleton North | 3.6 mi | ★★★★★ | 3 | 1 |
| Rennes Health And Rehab Center-appleton | 3.7 mi | ★★★★★ | 0 | 0 |
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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.