Meadowbrook at Appleton

In the surveyor’s words

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

• Immediate jeopardy, isolatedF805Apr 2, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF684May 5, 2021

  Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to maintain the highest practical physical well-being in accordance with professional standards of practice related to wound management for 2 Residents (R) (R1 and R4) of 3 sampled residents, resulting in R1 requiring further surgical intervention and potential additional amputation. R1 was readmitted to the facility on [DATE] with a right below-the-knee amputation (BKA) along with orders for daily dressing changes and Rigid Removable Device (RRD) (protective covering for amputation wounds) to be in place 23 hrs./day. R1's surgical wound was not assessed upon admission on 4/9/21. R1's treatment orders were not initiated until 4/13/21 (4 days after admission). […]

• Actual harm, isolatedF686Jun 25, 2025

  Based 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). […]

• Actual harm, isolatedF686Apr 18, 2022

  Based on observation, interview and record review, the facility did not ensure necessary care and services were provided to promote healing and/or prevent pressure injuries from worsening/developing for 2 Residents (R) (R195 and R3) of 6 sampled residents reviewed for pressure injuries. R195 admitted to facility with several pressure injuries. Facility did not consistently administer physician ordered treatments and failed to maintain specialty mattress at correct setting to reduce pressure which caused R195's sacral (lower back near buttocks) pressure injury to worsen. R3 developed a Stage IV pressure injury in June of 2020. […]

• No harm, potential for more than minimal, widespreadF801Oct 22, 2025

  Based 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.Findings include: The facility's Dietitian policy, revised February 2021, indicates: .7. If a Dietitian is not employed full time (35 or more hours per week) a Director of Food Service Management will be designated. This individual will: a. Be a certified Dietary Manager; or b. […]