Avina of Fond Du Lac

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the provision of foot and nail care for 1 of 3 residents (R2) in a total sample of 9 residents. The facility did not provide toe nail care for R2 in accordance with their care plan or the facility's policy.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the accurate administration of medication for 1 of 5 residents (R1) in a total sample of 9 residents. R1 had an order for sliding scale insulin to be administered before meals. R1's insulin was not administered in accordance with the order.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was served at a palatable and appetizing temperature for 3 of 9 sampled residents (R3, R4, and R5). R3, R4, and R5 indicated the facility's food was not palatable and was served at an unappetizing temperature. During the lunch meal on 7/6/26, a test tray contained items that were served below the appropriate temperatures.

Inspectors wroteBased on observation and staff, resident, and family interview, the facility did not ensure a clean, comfortable, home-like environment for residents on the 100 wing. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. A black and/or green, damp, and smudgeable substance was observed on walls and ceiling tiles on the 100 wing. In addition, a brown fuzzy growth was observed on a ceiling tile directly above the entrance to the common area/living room on the 100 wing.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of drugs and biologicals for 1 resident (R) (R1) of 5 sampled residents. On 3/13/26, Licensed Practical Nurse (LPN)-I did not administer R1's dose of Estradiol as ordered.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure a care plan was updated in a timely manner for 1 resident (R) (R2) of 4 sampled residents. R2's care plan was not updated in a timely manner after a resident-to-resident altercation.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the right to make healthcare decisions was provided for 1 resident (R) (R1) of 1 sampled resident. R1's Power of Attorney for Healthcare (POAHC) was not activated; however, R1's medical record contained multiple documents signed by POAHC-F. The facility did not have documentation that R1 consented to POAHC-F signing documents on R1's behalf.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a clean, comfortable, or homelike environment for 1 resident (R) (R6) of 10 sampled residents. R6 reported to staff that the faucet in R6's bathroom did not work properly. The faucet was not repaired in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of drugs and biologicals for 2 residents (R) (R1 and R7) of 8 sampled residents. On 9/11/25, Medication Technician (MT)-G administered another resident's medications to R1 and R7.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 43 residents residing in the facility. The facility did not have an RN on duty 8 consecutive hours per day 7 days per week on 1/4/25, 1/5/25, and 2/16/25. From 7/15/25 through 7/17/25, Surveyor reviewed the nurse staffing schedules for sampled days based on the facility's Payroll Based Journal (PBJ). The facility triggered for low weekend staffing for Fiscal Year (FY) Quarter 2 (January 2025 through March 2025). The facility did not trigger for No RN Hours. The facility provided schedules for the following requested dates: 1/3/25, 1/4/25, 1/5/25, 1/6/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 3/21/25, 3/22/25, 3/23/25, and 3/24/25. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the safe and accurate administration of medication for 4 residents (R) (R3, R18, R28, and R7) of 23 sampled residents. Medication was observed on R3's overbed table. R3 did not have an assessment or a physician's order that indicated R3 could self-administer medication or store medication at the bedside. Medications were observed in a bin in R18's room and on R18's bedside table. R18 did not have an assessment or a physician's order that indicated R18 could self-administer medication or store medication at the bedside. In addition, R18 did not have an order for one of the medications. Medication was observed on R28's overbed table. R28 did not have an assessment or a physician's order that indicated R28 could self-administer medication or store medication at the bedside. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R16) of 23 sampled residents. During multiple observations, R16's call light was not within reach. In addition, R16's ability to use the call light was not assessed.

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures to prevent abuse for 3 ((Certified Nursing Assistant)-C, CNA-D, and Laundry Aide (LA)-E) of 8 employees reviewed for caregiver background checks. The facility did not ensure Background Information Disclosure (BID) forms were signed and dated for CNA-C, CNA-D, and LA-E.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure range of motion (ROM) exercises were completed in accordance with a range of motion program for 1 resident (R) (R6) of 1 sampled resident. An occupational therapy (OT) discharge note indicated R6 was provided ROM exercises to decrease contractures and maintain ROM. R6's plan of care did not include the ROM exercises and staff did not provide ROM for R6.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an evaluation of smoking risks was completed for 1 resident (R) (R29) of 2 sampled residents. A Comprehensive Smoking Evaluation, dated 10/21/24, indicated R29 required supervision while smoking. On 7/10/25, staff completed a Smoking Quarterly Review that indicated R29 did not require supervision while smoking. Staff did not complete a comprehensive evaluation that supported the change from supervised to unsupervised smoking.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R35) of 23 sampled residents received the necessary care and services to prevent or monitor weight loss. R35 had a significant weight loss. Appropriate follow-up was not completed, including timely notification of the physician, Registered Dietitian (RD), and R35's Power of Attorney for Healthcare (POAHC).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the necessary respiratory care and services were provided for 3 residents (R) (R2, R26, and R3) of 3 sampled residents. R2 used a nebulizer (a machine that transforms liquid medication into a fine mist that can be inhaled directly into the lungs) but did not have an order to clean the nebulizer after use. In addition, R2's care plan did not address how to clean or care for the nebulizer. R2 also used a continuous positive airway pressure (CPAP) machine but did not have orders for settings or maintenance of the machine. R26 used a nebulizer but did not have an order or care plan that addressed how to properly clean or care for the nebulizer after use. R3 had an order for as needed (PRN) oxygen that did not specify a flow rate. In addition, R3's plan of care did not indicate R3 used oxygen.

Inspectors wroteBased on staff interview and record review, the facility did not ensure ongoing communication with a dialysis facility for 1 resident (R) (R2) of 1 resident who received dialysis services. R2 received dialysis three times per week. The facility did not ensure ongoing communication between the nursing facility and the dialysis facility prior to and following R2's dialysis appointments. In addition, R2's medical record did not specify which days of the week R2 went to dialysis.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure dishes were washed and food was prepared in a safe and sanitary manner. This practice had the potential to affect all 46 residents residing in the facility. Staff did not appropriately test the sanitizing solution in the dishwashing sink. Cook (CK)-C did not wear gloves or wash hands appropriately when preparing pureed fish.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R10 and R11) were allowed continued use of assistive devices to enhance their quality of life. When R10 and R11 were admitted to the facility, R10 and R11 were allowed to use an electric wheelchair/ motorized scooter inside the facility. R10 and R11 were no longer allowed to to use the devices inside the facility after the facility changed their policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 46 residents residing in the facility. The facility did not have an RN on duty for 8 consecutive hours per day 7 days per week on 24 of 26 days reviewed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 46 of 46 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R8) of 1 resident reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R8 was transferred to the hospital on 3/4/24 and 4/28/24. R8 was not provided with a written transfer notice for either transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure neurological checks were completed per policy for 2 residents (R) (R35 and R38) of 4 residents reviewed for falls. Staff did not consistently complete neurological checks after R35 fell on 2/3/24, 2/21/24, 4/13/24, and 4/21/24. Staff did not consistently complete neurological checks after R38 fell on 3/28/24.

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R3 and R2) of 3 sampled residents. In addition, the facility did not report an allegation of neglect to the State Agency (SA) for 1 (R1) of 3 sampled residents. The facility did not report an allegation of sexual abuse involving R3 and R2 to the SA, local law enforcement, R3's Power of Attorney for Healthcare (POAHC), or R2's court-appointed guardian. The facility did not report an allegation of neglect involving R1 to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 residents (R) (R3, R2, and R1) of 3 sampled residents. The facility did not thoroughly investigate an allegation of sexual abuse involving R3 and R2. The facility did not thoroughly investigate an allegation of neglect involving R1.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an assessment was completed by a Registered Nurse (RN) when a change in condition occurred for 1 Resident (R) (R2) of 3 residents reviewed. R2 had a change in condition that included slurred speech, increased confusion, and a left eye that wouldn't open. R2 was not assessed by an RN. R2 was sent to the hospital approximately two hours later and underwent brain surgery for a stroke.

Inspectors wroteBased on resident and staff interviews and record review, the facility did not ensure a safe discharge for 1 of 3 residents R1 (Resident) reviewed for discharge. Prior to admission R1 lived in a motorhome in a campground, which is not wheelchair or walker accessible and has a [NAME] bed. On 10/13/23, R1 was taken, by transport van, to his motorhome, with 2 staff accompanying. R1 was unable to navigate the three steps into the motorhome with staff assistance. R1 started to fall backwards, and staff assisted R1 into his wheelchair. Staff observations of the interior of R1's motorhome were it was uninhabitable, with multiple jugs of urine, no bathroom facilities, no running water, no food, and full of junk. Staff contacted NHA A (Nursing Home Administrator) to make her aware of their observations. [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility did not ensure all allegations of abuse were reported timely to the State for 2 Residents (R4 and R9) of 11 sampled residents. R4 had an altercation with a staff member around other residents. The facility did not report the incident to the State. R9 complained that a staff member was rude, constantly yelling, and laughs at him. The facility did not report the incident to the State.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure that all alleged violations involving abuse were fully investigated and the resident was protected during the investigation in accordance with State law through established procedures in 2 of 3 alleged abuse investigations out of a total sample of 11 residents reviewed (R4 and R9). R4 had an altercation with a staff member around other residents. The facility did not investigate the concern. R9 complained that a staff member was rude, constantly yelling, and laughs at him. The facility did not fully investigate the concern.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R10) of 5 residents. R10 did not receive pain and anxiety medications timely because the facility did not have the medications available.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection control program designed to help prevent the development and transmission of disease and infection for 1 Resident (R) (R8) of 6 residents observed for infection control practices. Certified Nursing Assistant (CNA)-D did not appropriately change gloves and cleanse hands during the provision of cares for R8.