Appleton, WI

Peabody Manor

4-star overall rating with 3-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

2600 S Heritage Woods Dr, Appleton, WI

(920) 738-3000

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1994-10-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.78

Registered nurse staffing

LPN hours / resident day

0.54

Licensed practical nurse staffing

Aide hours / resident day

2.34

Nurse aide staffing

Weekend hours

4.18

Weekend nurse staffing

RN turnover

48%

Annual RN turnover

Total nurse turnover

52%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.1%	95.7% 0.4 pts better	93.4% 2.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.5%	95.0% 0.5 pts better	95.5% About the same	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.2% 1.9 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	3.8%	5.0% 1.2 pts better	11.4% 7.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	3.0%	4.9% 1.9 pts better	5.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.9%	16.6% 3.3 pts worse	19.6% 0.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	14.6%	16.7% 2.1 pts better	16.7% 2.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	28.0%	21.1% 6.9 pts worse	16.3% 11.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	19.2%	17.3% 1.9 pts worse	14.9% 4.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.1%	2.3% 0.2 pts better	1.0% 1.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	2.6%	3.0% 0.4 pts better	1.7% 0.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.4%	25.5% 5.1 pts better	19.8% 0.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	10.5%	5.5% 5 pts worse	5.1% 5.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	86.8% 11.8 pts better	81.7% 16.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	18.7%	15.0% 3.7 pts worse	12.0% 6.7 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.3% 0.6 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.5%	82.2% 15.3 pts better	79.7% 17.8 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.2%	22.7% 9.5 pts better	23.9% 10.7 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-18 · Fire 2024-12-18

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

12 fire-safety deficiencies

Top issue: Miscellaneous (3 deficiencies)

Cycle 2 Health 2023-09-13 · Fire 2023-09-13

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

13 fire-safety deficiencies

Top issue: Emergency Preparedness (8 deficiencies)

Cycle 3 Health 2022-10-05 · Fire 2022-10-05

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-18

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2025-01-15

F · Potential for more than minimal harm 2024-12-18

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-01-15

F · Potential for more than minimal harm 2024-12-18

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-01-13

F · Potential for more than minimal harm 2024-12-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-22

E · Potential for more than minimal harm 2024-12-18

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-01-13

E · Potential for more than minimal harm 2024-12-18

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-01-14

E · Potential for more than minimal harm 2024-12-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-01-15

E · Potential for more than minimal harm 2024-12-18

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2025-01-15

E · Potential for more than minimal harm 2024-12-18

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-01-15

E · Potential for more than minimal harm 2024-12-18

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-01-13

E · Potential for more than minimal harm 2024-12-18

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-01-13

D · Potential for more than minimal harm 2024-12-18

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-01-15

F · Potential for more than minimal harm 2023-09-13

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2023-10-06

F · Potential for more than minimal harm 2023-09-13

E23 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for medical documentation.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

E33 · Emergency Preparedness Deficiencies

Fire Safety

Establish methods for sharing information.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-10-05

F · Potential for more than minimal harm 2023-09-13

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-10-31

F · Potential for more than minimal harm 2023-09-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-05

C · Minimal harm 2023-09-13

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-09-29

C · Minimal harm 2023-09-13

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-10-05

F · Potential for more than minimal harm 2022-10-05

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2022-10-28

F · Potential for more than minimal harm 2022-10-05

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-10-28

E · Potential for more than minimal harm 2022-10-05

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-10-28

D · Potential for more than minimal harm 2022-10-05

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-10-05

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-10-07

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-07-07

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-30

D · Potential for more than minimal harm 2025-07-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-07-30

G · Actual harm 2024-12-18

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-18

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-18

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-18

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-06-05

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-07-01

D · Potential for more than minimal harm 2024-06-05

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-07-01

F · Potential for more than minimal harm 2023-09-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-09-13

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-10-02

D · Potential for more than minimal harm 2023-09-13

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-09-13

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-10-30

D · Potential for more than minimal harm 2023-09-13

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-10-02

D · Potential for more than minimal harm 2023-09-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-06

F · Potential for more than minimal harm 2022-10-05

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-10-31

D · Potential for more than minimal harm 2022-10-05

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2022-10-28

D · Potential for more than minimal harm 2022-10-05

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-10-28

D · Potential for more than minimal harm 2022-10-05

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-10-31

D · Potential for more than minimal harm 2022-10-05

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-10-31

D · Potential for more than minimal harm 2022-10-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-12-31

D · Potential for more than minimal harm 2022-10-05

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2022-12-31

D · Potential for more than minimal harm 2022-10-05

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-12-31

Penalties and ownership