Meadowbrook at Appleton

Inspectors wroteBased on staff interview and policy review, the facility did not ensure a qualified person was designated to serve as the Dietary Manager. This practice had the potential to affect kitchen sanitation and quality of care related to food and nutrition for all 35 residents residing in the facility. The former Dietary Manager left employement with the facility in October. The Administrator was acting as the Dietary Manager. The Administrator was not certified in food service management.

Inspectors wroteBased on staff interview and record review, the facility did not notify a representative when an antipsychotic medication was increased for 1 resident (R) (R1) of 3 sampled residents. R1 was prescribed an atypical antipsychotic medication. R1's representative was not notified when the dose of the medication was increased.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 46 residents residing in the facility. The facility did not monitor and document food cooling temperatures. Staff did not test the Quaternary sanitizing solution (used to sanitize food preparation surfaces) per manufacturer's instructions. In addition, the facility did not monitor the Quaternary sanitizing solution for proper water temperature and parts per million (PPM).

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure food was served at a safe and appetizing temperature for 5 residents (R) (R5, R6, R8, R12, and R30) of 16 sampled residents. During interviews on 7/21/25 and 7/22/25, R5, R6, R8, R12 and R30 indicated their food was not appetizing and was served at a temperature they did not prefer. A test tray obtained during meal service on 7/22/25 indicated the food was not served at a palatable temperature.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 3 residents (R) (R5, R7, and R6) of 16 sampled residents were given the right to participate in care planning. R5 was admitted to the facility in December of 2024. R5's medical record did not contain documentation of any care conferences. R7 was admitted to the facility in August of 2024. R7's medical record did not contain documentation of any care conferences. R6 was admitted to the facility in November of 2024. R6's medical record did not contain documentation of any care conferences.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R28) of 17 sampled residents was offered the opportunity to create or obtain Power of Attorney for Healthcare (POAHC) paperwork. R28 was admitted to the facility on [DATE]. The facility did not obtain R28's POAHC document or offer R28 the chance to fill out a new document prior to 7/21/25.

Inspectors wroteBased on observation and staff and resident interview, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R31) of 16 sampled residents. The facility did not ensure food debris, spills, dirt, and used medical supplies were removed from R31's floor or that R31's garbage was emptied in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not develop a comprehensive bowel and bladder care plan for 1 resident (R) (R7) of 16 sampled residents. R7 was admitted to the facility in August of 2024. Documentation indicated R7 was occasionally incontinent of bladder, typically during the night. R7's comprehensive care plan, updated on 5/16/25, did not include problems, goals, or interventions related to incontinence.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R25) of 4 sampled residents. R25 fell on 5/2/25. An intervention was added to R25's care plan to ensure R25's bed was in the lowest position. The intervention was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the appropriate care and services for 2 residents (R) (R31 and R25) of 3 sampled residents with an indwelling catheter. R31 recently recovered from a urinary tract infection (UTI). On 7/21/25, R31's uncovered catheter bag was observed on the floor. R25 had a history of UTIs. On 7/22/25, R25's catheter bag was observed on the floor.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R35 and R4) of 2 sampled residents who were fed via enteral feeding (a way of sending nutrition right to the stomach or small intestine via tube) received care and services to avoid complications. On 7/21/25, Registered Nurse (RN)-C did not check for placement or residual prior to administering medication and enteral feeding to R35 .On 7/21/25 Licensed Practical Nurse (LPN)-H did not check placement or residual prior to administering medication to R4.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R5) of 2 sampled residents. R5 had an order for a Fentanyl patch for pain to be changed every three days. During observations on 7/21/25 and 7/22/25, R5's Fentanyl patch was dated 7/17/25. R5 stated R5 felt achy and had difficulty sleeping.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure transmission-based precautions (TBP) were implemented for 1 resident (R) (R52) of 2 residents with a diagnosis of a transmittable infection. R52 had diagnoses of sepsis and pneumonia and was placed on droplet precautions. Staff did not don the appropriate personal protective equipment (PPE) when entering R52's room on 7/21/25 and 7/22/25.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure they completed regular pest control which affected 1 resident (R) (R30) of 17 sampled residents. R30 indicated there were fruit flies in R30's room and R30 had a bug bite on the right hand. The facility did not ensure they completed regular pest control.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R13) of 2 sampled residents. R13 was admitted to the facility on [DATE] with a stage 4 pressure injury on the right hip and a wound vac (a device used to promote healing in wounds that are slow to close that includes a sealed dressing and a vacuum pump which helps remove fluid and bacteria, reduce swelling, and encourage new tissue growth). On 6/18/25, Wound Nurse Practitioner (WNP)-P indicated R13's wound vac dressing had been applied incorrectly which caused the skin around the wound to deteriorate and the wound to increase in size.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 4 residents (R) (R7, R12, R15, and R17) of 19 sampled residents were provided safe administration of drugs and biologicals. On 6/24/25, Surveyor observed an albuterol inhaler and a vial of DuoNeb solution on R7's bedside table. Surveyor also observed a nebulizer on the nightstand that contained a full chamber of solution. R7 did not have a physician's order or self-administration of medication assessment that indicated R7 could self-administer medication. On 6/24/25, Surveyor observed a 1 ounce bottle of Afrin nasal spray on R12's nightstand. R12 did not have a physician's order for Afrin nasal spray or a self-administration of medication assessment that indicated R12 could self-administer medication or store medication at the bedside. [...]

Inspectors wrote2. The 2022 Federal Food and Drug (FDA) Food Code documents at 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: .(B) With tight-fitting lids or doors if kept outside the food establishment . On 6/24/25 at 7:33 AM, Surveyor conducted an environmental tour of the facility and noted a garbage dumpster in the rear parking lot was open on top and in the back. On 6/24/25 at 2:38 PM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. On 6/25/25 at 8:25 AM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure Informed Consent for Medication forms were signed or verbal consent was obtained prior to administering psychotropic medication for 1 resident (R) (R6) of 1 sampled resident. R6 was administered psychotropic medication without written or verbal consent from R6's Power of Attorney for Healthcare (POAHC).

Inspectors wroteBased on staff interview and record review, the facility did not ensure a allegation of misappropriation was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident. On 5/16/25, R3 reported to the facility that R3 was a missing a blue jacket worth $75. The facility did not provide staff education on misappropriation of resident property or documenting residents' personal property upon admission despite the fact education was listed as an immediate and ongoing intervention in the facility's investigation.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure staff provided activities of daily living (ADLs) in accordance with preferences for 1 resident (R) (R13) of 19 sampled residents. R13 was dependent on staff for oral care, pericare, and personal hygiene and filed a grievance on 5/26/25 regarding the provision of timely care. The grievance indicated the issue was resolved, however, staff continued to not provide care in a timely manner or at R13's preferred time of day.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the appropriate care and treatment was provided for a peripherally inserted central catheter (PICC) line for 1 resident (R) (R4) of 5 sampled residents. R4 had a PICC line. Staff did not complete a PICC line dressing change as ordered and in accordance with the facility's policy.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R16) of 19 sampled residents. R16's bilevel positive airway presure (BiPAP) machine and equipment were not properly cleaned or cared for in accordance with the facility's policy.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was prepared in a form designed to meet the requirements of a mechanical soft diet for 1 resident (R) (R8) of 1 sampled resident. R8 had an order for a mechanical soft diet (smaller than bite-sized pieces/chopped). On 6/24/25, R8's lunch tray was delivered to the unit with regular texture roast beef.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, or resolved for 1 resident (R) (R4) of 9 sampled residents. R4's legal representative expressed concerns following R4's respite stay at the facility. The facility did not appropriately document, investigate, or thoroughly resolve the grievance.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This practice has the potential to affect all 46 residents residing in the facility. Dietary Manager (DM)-C did not complete an approved dietary manager or food service manager certification course or other related education.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 5 residents (R) (R1, R4, R5, R8, and R9) of 5 residents. This practice had the potential to affect multiple other residents in the facility. R1, R4, R5, R8, and R9 were ordered carbohydrate-controlled diets. R1, R4, R5, R8, and R9's meal tickets did not contain diet modifications and the residents were served regular diet portions of dessert. In addition, dietary staff did not serve residents recommended portion sizes for all diet types.

Inspectors wroteBased on staff interview and record review, the facility did not ensure neurological checks were completed per the facility's policy after a fall for 1 resident (R) (R1) of 1 sampled resident. Staff did not consistently complete neurological checks after R1 fell on 8/12/24 and 9/8/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 40 residents residing in the facility. The facility did not have a system for monitoring cooked food temperatures or hot/cold holding temperatures. Staff did not practice safe food handling by donning hair and beard restraints while cooking and serving food.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the individual designated as the food and nutritional services director met the minimum qualifications for the role. This had the potential to affect 47 of 48 residents residing in the facility. Dietary Manager (DM)-G did not complete an approved dietary manager or food service manager certification course or other related education.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 47 of 48 residents residing in the facility. Staff did not monitor or document food cooling temperatures. The handwashing sink did not reach the required minimum temperature for proper hand hygiene. A can opener was not properly cleaned. Staff left visibly soiled oven mitts on top of condiment containers. Chemicals used for cleaning were stored by food containers and near food preparation areas. On two occasions, three resident room trays were delivered to the floor uncovered and on top of the food cart. Staff did not test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 48 residents residing in the facility. Director of Nursing (DON)-B was the facility's designated IP. DON-B did not complete specialized training for infection prevention and control.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R25) of 14 sampled residents was offered the opportunity to create or obtain Power of Attorney for Health Care (POAHC) paperwork. R25 was admitted to the facility on [DATE]. The facility did not obtain R25's POAHC document or offer R25 the chance to fill out a new document prior to 5/7/24.

Inspectors wroteBased on staff interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) for when 1 resident (R) (R34) of 14 sampled residents experienced a change in condition. The facility did not notify R34's POAHC following a fall on 5/1/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R145 and R32) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R145 was transferred to the hospital on 4/18/24 and was not provided with a written transfer notice. R32 was transferred to the hospital on 3/10/24. R32 and/or R32's legal representative were not provided with a written transfer notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R145 and R32) of 2 residents reviewed for hospitalization received notification of the facility's bed hold policy when they were transferred to the hospital. R145 was transferred to the hospital following a fall on 4/18/24. R145 was not provided written notice of the facility's bed hold policy. R32 was transferred to the hospital on 3/10/24. R32 was not provided written notice of the facility's bed hold policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive assessment was completed after a significant change in condition for 1 resident (R) (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24. The facility did not complete comprehensive assessment for a significant change in condition.

Inspectors wroteBased on staff interview and record review, the facility did not develop a baseline care plan that included the minimum healthcare information necessary to properly care for 1 resident (R) (R149) of 14 sampled residents. R149's baseline care plan did not include information related to R149's dialysis, diet, and smoking status.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24. The facility did not develop a care plan to address R8's Hospice care. In addition, R8 did not have an order for Hospice prior to 5/8/24

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R33 and R4) of 2 residents reviewed for pressure injuries received the necessary care and services to promote healing. R33 had an order to remove R33's wound vac on 3/13/24 and reapply the wound vac on 3/20/24. On 3/20/24, the order was changed to reapply the wound vac on 3/27/24. The facility did not reorder wound vac supplies in a timely manner and the wound vac was not reapplied until 4/10/24. R4 had a pressure injury on the coccyx and an order to cleanse the wound with Vanshe wound cleanser. During an observation of wound care on 5/8/24, staff did not use Vanshe cleanser during R4's dressing change and stated the facility was out of the cleanser.

Inspectors wroteBased on staff interview and record review, the facility did not provide adequate monitoring post fall for 1 resident (R) (R34) of 2 residents reviewed for falls. The facility did not complete neurological checks per their policy after R34's unwitnessed falls on 9/21/23 and 10/21/23.

Inspectors wroteBased on observation, record review, and staff interview, the facility did not ensure respiratory equipment was routinely cleaned for 2 residents (R) (R145 and R156) of 2 sampled residents. Staff did not clean R145 and R156's continuous positive airway pressure (CPAP) equipment and did not change R145 and R156's oxygen tubing per the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure ongoing communication and collaboration with the dialysis center for 1 resident (R) (R17) of 2 resident reviewed for dialysis services. R17 received peritoneal dialysis daily at the facility and had an order for daily weights. R17's daily weight was not obtained on 8 out of 38 days. In addition, R17's physician orders were not clarified and the physician was not notified of weight increases above the specified parameters.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician order was transcribed for 1 resident (R) (R4) of 5 sampled residents. R4's hospital discharge paperwork, dated 4/4/24, contained an order for emergency administration of diazepam (an anxiolytic and sedative medication) during a seizure lasting longer than three minutes. The order was not transcribed in R4's medical record.

Inspectors wroteBased on staff interview and record review, the facility did not ensure medication regimens were reviewed monthly and pharmacy recommendations were reviewed and acted upon by a physician for 1 resident (R) (R32) of 5 sampled residents. A monthly medication regimen review (MRR) was not completed for R32 in September 2023, October 2023, November 2023, December 2023, January 2024, and March 2024. In addition, pharmacy recommendations for April 2024 were not acted upon or reviewed by R32's physician.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R15 and R4) of 2 residents were provided services to help prevent the transmission of infection. R15 had an order for droplet precautions pending further testing related to respiratory concerns. On 5/8/24, Surveyor observed Certified Nursing Assistant (CNA)-I assist R15's roommate (R4) with a room tray. CNA-I did not wear personal protective equipment (PPE) in the room. During an observation of wound care on 5/8/24, Registered Nurse (RN)-H reached beneath RN-H's gown to obtain a flashlight and scissors from RN-H's pocket. Without disinfecting the scissors, RN-H used the scissors to cut a dressing used to pack R4's wound.

Inspectors wroteBased on staff interview and record review, the facility did not ensure influenza B and pneumococcal vaccinations were reviewed, offered, and administered for 3 residents (R) (R8, R2, and R4) of 5 sampled residents. The facility did not review R8's vaccination history or offer R8 the PCV20 (Prevnar 20®) and influenza B vaccines. The facility did not review R2's vaccination history or offer R2 the Prevnar 20® and influenza B vaccines. The facility did not review R4's vaccination history or offer R4 the Prevnar 20® vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunization for 3 residents (R) (R19, R2, and R7) of 5 sampled residents. In addition, the facility did not implement a COVID-19 immunization program for staff. R19, R2, and R7's medical records did not include documentation that indicated the facility offered or administered COVID-19 immunizations. The facility did not have proof of a COVID-19 immunization program for staff.

Inspectors wroteBased on staff interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 resident (R) (R1) of 4 residents who had an order for a mechanically-altered diet. R1 was admitted to the facility on [DATE] following a hospitalization. R1's hospital discharge orders indicated R1 should receive a pureed diet, however, staff transcribed R1's diet order as mechanical soft with nectar-thickened liquids. On 3/13/24, R1 received the wrong meal tray and was served food that was not in accordance with R1's diet order. R1 aspirated, required hospitalization, and passed away on 3/23/24 from respiratory failure secondary to aspiration pneumonia. The facility's failure to prepare and serve food in a form to meet a resident's needs created a finding of Immediate Jeopardy that began on 3/13/24. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide treatment and care in accordance with professional standards of practice for 1 Resident (R) (R1) of 3 sampled residents. R1 received two different narcotic pain medications together multiple times between 1/13/24 and 1/22/24 which affected R1's mentation.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate supervision to prevent accidents was provided for 1 Resident (R) (R2) of 10 sampled residents. The facility did not reassess R2 for elopement risk or revise R2's care plan after R2 left the faciity on 9/15/23.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This had the potential to affect all 40 residents residing in the facility. The facility did not monitor and document food cooling and holding temperatures. Staff did not test quaternary sanitizing solution per manufacturer's instructions.

Inspectors wroteBased on staff interview and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. This had the potential to affect all 40 residents residing in the facility. The facility did not conduct continuous infection surveillance including tracking and trending of illnesses, potential infectious agents, and monitoring of staff signs and symptoms of infection or potential infection. The facility did not provide a cover for R23's catheter drainage bag which was observed dragging on the floor from 3/27/23 to 3/29/23. R23 had a history of urinary tract infections (UTIs) and was currently being treated with an antibiotic for a UTI.

Inspectors wroteBased on staff interview and record review, the facility did not have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control. This had the potential to affect all 40 residents residing in the facility. Director of Nursing (DON)-B started as the facility's IP in December of 2022; however, DON-B did not complete specialized training for infection prevention and control. DON-B accepted the Director of Nursing role in February of 2023. Assistant Director of Nursing (ADON)-C started at the facility in March of 2023 and assisted with IP duties; however, ADON-C did not complete specialized training for infection prevention and control.

Inspectors wrote2. On 3/29/23, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] with diagnoses to include cardiomyopathy (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). R24's medical record contained the following physician orders: ~ Apixaban Tablet 5 mg (milligrams) - Give 5 mg by mouth two times a day ~ Hydrocodone-Acetaminophen Tablet 5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain ~ Furosemide Tablet 40 mg Give 0.5 tablet by mouth one time a day .Give 20 mg daily Surveyor noted R24's care plan did not address R24's need for and use of apixaban, hydrocodone-acetaminophen and furosemide, including monitoring for side effects related to the medications. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 2 Residents (R) (R8 and R30) of 13 sampled residents. R8's Level I and Level II PASRR Screens were not completed timely. R30's Level I PASRR Screen was not completed timely.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an accurate nutrition assessment was completed for 1 Resident (R) (R19) of 3 sampled residents reviewed for nutrition concerns. The facility did not complete an accurate nutrition assessment or update the physician when R19 had a significant weight loss of 18 pounds (6%) between 1/13/23 and 1/18/23.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure consistent communication for 1 Resident (R) (R6) of 1 resident who received dialysis services. The facility did not provide R6 with a dialysis communication binder prior to routine dialysis appointments and did not have evidence of communication between the facility and the dialysis center on R6's dialysis days.

Inspectors wroteBased on observation, staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 3 Residents (R) (R4, R9, and R23) of 13 sampled residents. R4's medications were left at the bedside for R4 to self-administer. R4 did not have a physician's order to self-administer medication and was not assessed to determine if R4 could safely do so. R9's Humalog solution (Insulin Lispro) (fast-acting insulin used to control high blood sugar) pen was not marked with an open date. Per manufacturer's recommendations, Insulin Lispro is less effective 28 days after opening. R23's Refresh eye drops were not marked with an open date. In addition, staff were unsure of the facility's policy and were unable to determine when to discard the eye drops after opening.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R23 and R27) of 2 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information. R27 was transferred to the hospital on 1/2/23, 1/31/23, 2/16/23, and 3/21/23. A written notice of transfer was not provided to R27's representative for any of the transfers. R23 was not provided a written notice of transfer when R23 was transferred to the hospital on 2/2/23 and 2/15/23.