Edenbrook of Appleton North

In the surveyor’s words

From the most serious findings on record at Edenbrook of Appleton North, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 9, 2026

  Based 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. […]

• Actual harm, isolatedF760Feb 21, 2023

  Based on interview and record review, the facility did not ensure 1 Resident (R) (R3) of 5 residents was free of a significant medication error. R3 received in error clonidine (an antihypertensive medication,) losartan potassium (an antihypertensive medication,) and furosemide (a diuretic medication) which resulted in the need for intravenous (IV) (a needle or tube inserted into the vein) therapy to improve hypotension (low blood pressure). Findings include: R3 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's dementia, congestive heart failure, chronic kidney disease, and diabetes. R3's Minimum Data Set (MDS) dated [DATE], contained a Brief Interview for Mental status (BIMs) score of 13 out of 15 which indicated R3 had intact cognition. […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF880Aug 6, 2025

  Based 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). […]

• No harm, potential for more than minimal, patternF880Jun 30, 2025

  Based 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. Findings include: The facility's Infection Control Program policy, dated [DATE], indicates: The infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. […]