Edenbrook of Appleton North: Fall Safety Failure - WI
The resident, identified in inspection records only as R4, had been flagged as a fall risk with impaired cognition. The problem, as inspectors documented it, was specific: R4 would remove gripper socks and attempt to transfer out of bed alone, without calling for help. To reduce that risk, staff had placed an intervention in R4's care plan after the August fall. A urinal would be kept at the bedside. If R4 needed to use the bathroom, the urinal would be there. R4 wouldn't have to get up alone.
On September 2, at 2:15 in the afternoon, a surveyor walked into R4's room and looked at the bedside. No urinal.
Fifteen minutes later, the surveyor sat down with Licensed Practical Nurse C, who confirmed what the surveyor had already seen. R4 did not have a urinal at the bedside. The nurse checked R4's bathroom as well. No urinal there either.
It is a short distance from a care plan to a bedside table. The intervention had been written down. Someone had decided it mattered enough to document. And then, at some point between August 12 and September 2, it stopped being anyone's job to make sure it was actually there.
Two hours after speaking with the nurse, the surveyor interviewed the Director of Nursing, identified as DON-B. The director confirmed that fall interventions should be in place for residents. That much was clear. But DON-B said she needed to review R4's care plan before she could say more, and added that she was unsure whether R4 was even capable of using a urinal.
That last detail is worth sitting with. The care plan had been written after the fall. Staff had decided a urinal at the bedside was the right intervention. But the director of nursing, on the day inspectors came, was uncertain whether the resident the plan was written for could actually use it. Either the intervention had been put in place without that question being answered, or the answer had been lost somewhere between August and September.
The inspection was classified as a complaint survey. The level of harm was listed as minimal harm or potential for actual harm, and the number of residents affected was listed as few.
What the inspection report does not say is whether R4 fell again. It does not say how many times staff had entered that room in the three weeks since the August fall, or whether anyone had noticed the urinal was missing before the surveyor did. It does not say whether DON-B, after reviewing the care plan, found the answer to her question about whether R4 could use a urinal, or what happened next.
What it does say is that R4, a person with impaired cognition who had already fallen once, was observed in bed without the one item staff had decided would help keep R4 from getting up alone and falling again.
A care plan is only as good as the staff who carry it out. The plan existed. The urinal did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenbrook of Appleton North from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Edenbrook of Appleton North in Appleton, WI was cited for violations during a health inspection on September 2, 2025.
The resident, identified in inspection records only as R4, had been flagged as a fall risk with impaired cognition.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.