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

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.78

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.54

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.34

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

4.66

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

2.31

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

4.18

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

1.35

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.17

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

2.00

CMS adjusted RN staffing hours

Adjusted total hours

5.24

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

48%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,621

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

43.45

Composite VBP score used to determine payment impact.

Payment multiplier

0.9965

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.95

Baseline 18.32% · Performance 18.67% · Measure score 5.95 · Achievement 5.95 · Improvement 0

Healthcare-associated infections

3.18

Baseline 6.47% · Performance 6.88% · Measure score 3.18 · Achievement 3.18 · Improvement 0

Total nurse turnover

1.65

Baseline 58.57% · Performance 56.94% · Measure score 1.65 · Achievement 1.65 · Improvement 0

Adjusted total nurse staffing

6.59

Baseline 4.90 hours · Performance 4.95 hours · Measure score 6.59 · Achievement 6.59 · Improvement 0.10

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.83%	10.72% 0.9 pts better	No Different than the National Rate · Eligible stays 93 · Observed rate 7.53% · Lower 95% interval 6.03%
Discharge to community	56.14%	50.57% 5.6 pts better	No Different than the National Rate · Eligible stays 87 · Observed rate 54.02% · Lower 95% interval 46.93%
Medicare spending per beneficiary	0.68	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 50 · Denominator 50
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 50
Discharge self-care score	56.25%	53.69% 2.6 pts better	Numerator 27 · Denominator 48
Discharge mobility score	45.83%	50.94% 5.1 pts worse	Numerator 22 · Denominator 48
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 50 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.88%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.59%
Staff COVID-19 vaccination coverage	6.9%	8.2% 1.3 pts worse	Numerator 8 · Denominator 116
Staff flu vaccination coverage	92.86%	42% 50.9 pts better	Numerator 130 · Denominator 140
Discharge function score	56.25%	56.45% 0.2 pts worse	Numerator 27 · Denominator 48
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	2.33%	96.28% 94 pts worse	Numerator 1 · Denominator 43
Resident COVID-19 vaccinations up to date	34.48%	25.2% 9.3 pts better	Numerator 10 · Denominator 29

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 · Q1 92.7% · Q2 97.2% · Q3 94.7% · Q4 100.0% · 4Q avg 96.1%
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 · 4Q avg 95.5%
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 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star
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 · Q1 6.1% · Q2 3.7% · Q3 2.9% · Q4 2.8% · 4Q avg 3.8%
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 · Q1 2.5% · Q2 6.1% · Q3 0.0% · Q4 3.2% · 4Q avg 3.0%
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 · Q1 17.5% · Q2 18.2% · Q3 25.8% · Q4 18.8% · 4Q avg 19.9%
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 · Q1 10.3% · Q2 20.8% · Q3 17.4% · Q4 11.1% · 4Q avg 14.6% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 28.0% · Used in QM five-star
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 · Q1 21.1% · Q2 15.6% · Q3 19.4% · Q4 20.7% · 4Q avg 19.2% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 5.3% · Q4 3.0% · 4Q avg 2.1% · Used in QM five-star
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 · Q1 2.4% · Q2 0.0% · Q3 2.6% · Q4 5.4% · 4Q avg 2.6% · Used in QM five-star
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 · Q1 16.3% · Q2 27.9% · Q3 22.7% · Q4 15.3% · 4Q avg 20.4%
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 · Q1 5.4% · Q2 8.9% · Q3 15.0% · Q4 13.2% · 4Q avg 10.5% · Used in QM five-star
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 · Q1 99.1% · Q2 98.3% · Q3 99.0% · Q4 97.9% · 4Q avg 98.6%
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 · Adjusted 18.7% · Observed 17.5% · Expected 10.5% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.7% · 4Q avg 0.7% · Used in QM five-star
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 · 4Q avg 97.5%
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 · Adjusted 13.2% · Observed 10.5% · Expected 19.0% · Used in QM five-star

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