Edenbrook of Appleton North: Wound Care Missed - WI
The resident, identified in inspection records as R1, had been admitted to the facility with multiple conditions including sepsis, cellulitis of the right lower limb, and a chronic ulcer with fat layer exposed. Their cognitive assessment showed moderately impaired mental function, scoring 9 out of 15 on a standard test.
Physician orders required daily wound care for the resident's right heel injury. The treatment protocol called for cleaning the wound with wound cleanser, patting it dry, applying Santyl medication to the wound bed, covering with Telfa dressing, and wrapping in Kerlix gauze every day during the day shift.
The facility's own policy manual spelled out the requirements clearly. Staff must verify physician orders before treatment, review the resident's care plan and diagnoses, date and initial wound dressings when applied, and document the date and time dressing changes occur in medical records.
None of that happened on December 4.
The resident's Treatment Administration Record for December 2024 showed the dressing change was simply not completed that day. No documentation. No treatment. No explanation in the medical record.
Six days later, a nurse practitioner examined the wound and found it had deteriorated. The deep tissue injury measured 1.5 centimeters by 3.5 centimeters by 0.1 centimeters deep. The surface area covered 5.25 square centimeters, with 80 percent dead tissue and 20 percent slough. Light fluid drainage was present, and the wound edges appeared "cliff-like."
The nurse practitioner's December 10 note attributed the wound's overall deterioration to "nutritional compromise." The resident was started on Prostat protein supplement, vitamin C, and a multivitamin.
When federal inspectors arrived at the facility in September 2025, they interviewed Director of Nursing B about the missed treatment. The nursing director verified that the dressing change had not been completed on December 4, 2024, and confirmed that the resident's deep tissue injury dressing should be changed daily.
The director told inspectors she expects staff to follow orders for daily wound care. She stated that the resident's wound care should be completed daily and documented in medical records.
The inspection found that Edenbrook of Appleton North failed to ensure appropriate pressure ulcer care for the resident. Federal regulators classified the violation as causing "minimal harm or potential for actual harm" and noted it affected "few" residents.
Deep tissue injuries represent one of the most serious forms of pressure wounds that can develop in nursing homes. They occur when underlying tissue is damaged, often appearing as purple or maroon discolored areas of intact skin. Without proper treatment, these injuries can rapidly progress to full-thickness wounds that expose bone and muscle.
The resident's wound care orders included Santyl, an enzymatic medication that helps remove dead tissue from wounds to promote healing. Missing even a single day of treatment can allow bacteria to proliferate and healthy tissue to deteriorate further.
Federal regulations require nursing homes to provide appropriate pressure ulcer care and prevent new ulcers from developing. Facilities must follow physician orders precisely and document all treatments in resident medical records.
The facility's own policies acknowledged these requirements but staff failed to follow them. The December 4 missed treatment occurred during a critical period when the resident's wound was already compromised and needed consistent daily attention.
By the time the nurse practitioner reassessed the wound six days later, the damage was documented. The injury had deteriorated overall, requiring additional nutritional interventions to support healing.
The inspection occurred nearly nine months after the missed treatment, suggesting the violation came to light through a complaint rather than routine monitoring. Federal inspectors reviewed medical records, interviewed staff, and observed facility operations before citing the wound care deficiency.
Edenbrook of Appleton North must now submit a plan of correction to federal regulators detailing how it will prevent similar violations. The facility has 14 days from receiving the inspection report to make its corrective action plan available to the public.
The resident with the deep tissue injury had a power of attorney for healthcare activated, indicating family involvement in medical decisions. The inspection report does not detail the current status of the wound or whether additional treatment complications occurred.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 16, 2026 · Our methodology
Edenbrook of Appleton North in Appleton, WI was cited for violations during a health inspection on September 2, 2025.
Their cognitive assessment showed moderately impaired mental function, scoring 9 out of 15 on a standard test.
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.
Frequently Asked Questions
- What happened at Edenbrook of Appleton North?
- Their cognitive assessment showed moderately impaired mental function, scoring 9 out of 15 on a standard test.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Appleton, WI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Edenbrook of Appleton North or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525484.
- Has this facility had violations before?
- To check Edenbrook of Appleton North's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.