Edenbrook of Appleton North

Inspectors wroteBased on interview and record review, the facility did not appropriately notify a physician after a change of condition for 1 resident (R) (R6) of 3 sampled residents. Registered Nurse (RN)-C administered three doses of nitroglycerine (a fast-acting medication used to relieve/prevent chest pain) to R6. RN-C notified the physician via fax instead of the on-call service.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 3 sampled residents at risk for wandering/elopement. R1 had a hsitory of elopement and WanderGuard (WG) removal (a device placed on a person to alert facility staff if the person is exiting an area unsupervised). Despite the fact that R1 removed the WG multipe times and exited the facility unsupervised, the facility failed to implement increased supervision for R1 or increased monitoring for WG placement. On 11/17/26 at approximately 10:00 PM, staff discovered R1 was not in the facility during rounds. R1 was last seen by staff in the dining room at approximately 9:45 PM. Staff searched the facility and surrounding area and located R1 in the bathroom of a local business one block away. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure pressure injury wound care was provided for 1 resident (R) (R1) of 2 sampled residents. R1 had a deep tissue injury on the right heel and a wound care order for daily dressing changes. R1's wound care order was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure appropriate fall interventions were in place for 2 residents (R) (R1 and R4) of 2 sampled residents. R1's falls care plan was not updated with an intervention after a fall on 12/12/24. R4's falls care plan contained an intervention for a urinal at bedside following a fall on 8/12/25. The intervention was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 68 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The walk-in cooler and dry storage area contained multiple undated and unlabeled items. The facility did not test Quaternary sanitizing solution used to sanitize food preparation areas in accordance with the manufacturer's instructions. The facility did not monitor warewashing temperatures to ensure minimum surface temperatures were achieved to prevent the spread of foodborne illness. Findings incude:Food Cooling:The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 4 residents (R) (R62, R1, R9, and R42) of 6 sampled residents. During an observation of pericare for R62, Certified Nursing Assistant (CNA)-D did not appropriately remove gloves and cleanse hands. R1 was on enhanced barrier precautions (EBP). During an observation of catheter irrigation, Licensed Practical Nurse (LPN)-G did not wear appropriate personal protective equipment (PPE). Following the provision of care, staff did not remove PPE and complete hand hygiene when exiting R9's room. R42 had a history of chronic urinary tract infections (UTIs). R42's uncovered catheter bag was observed on the floor.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R8) of 4 sampled residents received the necessary care and services to prevent or monitor weight loss. R11 had a significant weight loss of 6.1% from 6/2/25 to 7/1/25. The facility did not implement interventions to address R11's weight loss. R8's medical record indicated R8 had a 7.1% weight loss over a 1 month period. The facility did not address R8's weight loss when it was identified.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R29) of 4 sampled residents was monitored for adverse reactions to antibiotic medication. The facility did not monitor R29 for side effects or adverse reactions to ciprofloxacin (an antibiotic medication).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 72 residents (R) residing in the facility. Numerous supply carts for residents on enhanced barrier precautions (EBP) contained expired sanitizing wipes and/or expired hand sanitizer.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure residents were provided a home-like dining experience. This practice had the potential to affect more than 4 of the 72 residents (R) residing in the facility. Residents were served meals on disposable Styrofaom dishware. In addition, residents were not always given the option to eat in the dining room.

Inspectors wroteBased on staff interview and record review, the nurse staffing posting did not accurately reflect the number of nursing staff working in the facility and was not posted at the beginning of each shift or on weekends. This had the potential to affect all 67 residents residing in the facility. The nurse staffing posting did not accurately reflect the actual number of nursing staff who worked the 12/12/24 night (NOC) shift and was not posted at the start of the 12/13/24 AM shift. In addition, the facility did not post nurse staffing hours on the weekends.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R49) of 20 residents reviewed for advanced directives. R49 had a legal guardian. The facility did not petition or obtain court-ordered documents for protective placement when R49's stay in the facility exceeded 60 days from admission on [DATE].

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 employee (Certified Nursing Assistant (CNA)-C) of 8 employees reviewed for background checks. CNA-C was hired on 11/10/15. CNA-C's most recent background check was dated 11/8/19 which was not within the last 4 years.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Preadmission Screen and Resident Review (PASRR) for 1 resident (R) (R26) of 5 sampled residents was submitted for additional screening after the resident was diagnosed with a new mental illness and prescribed additional antipsychotic medication. R26's PASRR Level I Screen was completed upon R26's admission to the facility on 6/22/22. A PASRR Level II Screen was completed on 8/23/22. On 11/29/22, R26 received a new mental illness diagnosis of chronic paranoid schizophrenia and on 1/24/23, R26 was prescribed Vraylar (an antipsychotic medication) for paranoid schizophrenia. The facility did not update R26's PASRR Level I Screen and did not submit for a new PASRR Level II Screen.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 3 residents (R) (R19, R28, and R5) of 3 residents. R19 and R28 were on droplet precautions. During observations on 6/10/24, staff did not wear appropriate personal protective equipment (PPE) when they entered R19 and R28's rooms. R5 had a stage 3 pressure injury and was not on enhanced barrier precautions (EBP) as indicated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for two residents (R) (R14 and R40) of 5 sampled residents. R14's Power of Attorney (POA) signed consent forms on 9/15/23 and 2/22/24 for R14 to receive the PCV20 (Prevnar 20®) vaccine. The facility did not administer the vaccine. The facility did not offer R40 the PCV20 vaccine.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accuracy of admission orders and medication administration for 1 resident (R) (R276) of 6 sampled residents. R276 missed 3 doses of antirejection medication over a 3 day period until the medication order was clarified for proper dosage. In addition, R276 was administered 3 doses of medication from R276's home supply because staff could not locate R276's antirejection medication after it was delivered by the pharmacy.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not implement the comprehensive care plan for 1 Resident (R) (R1) of 16 residents reviewed for care plan implementation. The facility did not provide toileting for R1 as indicated in R1's person-centered comprehensive plan of care.

Inspectors wroteBased on observation and staff and resident interview, the facility did not provide adequate privacy curtains in double occupancy rooms for 2 Residents (R) (R32 and R39) of 17 sampled residents. R32 and R39 resided in double occupancy rooms with roommates. R32 and R39's rooms did not contain a full privacy curtain between the beds or around the shared sink to allow for privacy during the provision of care and personal hygiene. In addition, a shared sink was across from both beds in each room and in direct view of bed A as well as anyone who entered the room.

Inspectors wroteBased on staff interview and record review, the facility did not ensure assessments were accurate for 2 Residents (R) (R8 and R12) of 4 sampled residents. R8 had diagnoses of schizophrenia, major depressive disorder, and anxiety. R8's Minimum Data Set (MDS) assessment, dated 2/1/23, indicated R8 did not have a serious mental health diagnosis. R12 had diagnoses of major depressive disorder and anxiety. R12's MDS assessment, dated 4/16/23, indicated R12 did not have a serious mental health diagnosis.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (276) of 1 resident reviewed for indwelling catheters received the appropriate care and services to prevent a urinary tract infection (UTI). R276's catheter drainage bag was observed uncovered and/or resting on the floor on multiple occasions. In addition, R276's catheter tubing was observed underneath R276's left leg which obstructed the flow of urine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 68 residents residing in the facility. Director of Nursing (DON)-B, who was also the facility's wound care consultant, started as the facility's designated IP in January of 2023; however, DON-B did not complete specialized training in infection prevention and control.