Edenbrook Of Appleton North

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, staff interview, and record review, the facility did not ensure pressure injury wound care was provided for 1 resident (R) (Resident R1) of 2 sampled residents.Resident R1 had a deep tissue injury on the right heel and a wound care order for daily dressing changes. Resident R1's wound care order was not consistently followed.Findings include:The facility's Procedure Clean Dressing Change policy, dated 2/24/23, indicates: .1. Verify physician's order for the procedure/treatment. 2. Review the resident's care plan, current orders, and diagnoses as applicable to determine if there are special resident needs .16. Date and initial wound dressing when applied .Medical record documentation and follow-up as applicable: 1. The date and time the dressing was changed. On 9/2/25, Surveyor reviewed Resident R1's medical record. Resident R1 was admitted to the facility

on [DATE REDACTED] and had diagnoses including sepsis, cellulitis of right lower limb, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, and abrasion of left elbow. Resident R1's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated Resident R1 had moderately impaired cognition. Resident R1 had an activated Power of Attorney for Healthcare (POAHC). Resident R1's medical record contained the following orders:~ Treatment - Right Heel Betadine daily and as needed (PRN) every day shift for wound care (start date 11/26/24).~ Treatment Right Heel - Clean with wound cleanser, pat dry, apply Santyl to wound bed, apply Telfa, wrap in Kerlix daily and PRN every day shift for wound care (start date 12/3/24).Resident R1's December 2024 Treatment Administration

Record (TAR) indicated Resident R1's dressing change was not completed on 12/4/24.A Nurse Practitioner (NP) note, dated 12/10/24, indicated Resident R1 had what appeared to be a deep tissue injury (DTI) on the right heel that measured 1.5 centimeters (cm) x 3.5 cm x 0.1 cm. The surface area measured 5.25 square centimeters (cm2) with 80% eschar and 20% slough. There was light serous exudate, no induration, and

the edges appeared cliff-like. The peri-wound was normal in temperature and color. The note indicated the wound deteriorated overall due to nutritional compromise. Resident R1 was started on Prostat, vitamin C, and a multivitamin. On 9/2/25 at 3:01 PM, Surveyor interviewed Director of Nursing (DON)-B who verified Resident R1's dressing change was not completed on 12/4/24 and confirmed Resident R1's DTI dressing should be changed daily.

DON-B stated DON-B expects staff to follow orders for daily wound care and indicated Resident R1's wound care should be completed daily and documented.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Edenbrook of Appleton North

2915 N Meade St Appleton, WI 54911

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cognitive impairment.Resident R4's falls care plan, revised 8/20/25, indicated Resident R4 was at high risk for falls related to anoxic encephalopathy, impaired physical mobility, self-care deficit, fatigue, generalized weakness, cognitive impairment, decreased cardiac function, and hearing deficit. The care plan also indicated Resident R4 received antipsychotic and diuretic medication. Resident R4 was noted to remove gripper socks and attempted to self-transfer due to impaired cognition and was observed self-transferring alone without notifying staff of Resident R4's needs. The care plan contained an intervention to have a urinal at Resident R4's bedside which was initiated

after a fall on 8/12/25. On 9/2/25 at 2:15 PM, Surveyor observed Resident R4 in bed without a urinal at Resident R4's bedside.

On 9/2/25 at 2:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who confirmed Resident R4 did not have a urinal at the bedside. LPN-C checked Resident R4's bathroom and did not see a urinal there either.On 9/2/25 at 4:30 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed fall interventions should be in place for residents, however, DON-B needed to review Resident R4's care plan and was unsure if Resident R4 was capable of using a urinal.

Event ID:

Facility ID:

If continuation sheet