Avina of Kenosha

Inspectors wroteBased on interview and record review, the facility failed to ensure family was informed of a change in condition for one resident (Resident (R) 6) of 20 residents reviewed. The facility failed to inform family when R6 developed a stage 3 heel pressure ulcer (full thickness loss of skin).

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R3) of 3 residents reviewed for falls. R3 has a history of falls and is assessed to be at a high risk for falls. R3 has an active care plan intervention for Dycem (a versatile, non-slip material used for various applications, including wheelchair use) to be in place in R3's wheelchair to prevent falling. On 8/30/25, R3 slid out of R1's wheelchair and fell on the floor. R3 did not have Dycem in R3's wheelchair at the time of the fall.

Inspectors wroteBased on observation, record review, and interview the facility did not ensure that food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens.* On 7/22/25 , Surveyor observed Cook-D not wearing a facial hair restraint that completely covered his hair from contacting exposed food while pureeing a lunch item.* On 7/22/25, Surveyor observed Dietary Aide- E handling exposed foods without all of his hair under the hair restraint. Cook- D did not have his facial hair restrained while handling exposed foods preparing the lunch meal trays.* On 7/22/25, Surveyor observed Cook- D not clean the thermometer probe between different foods as Cook-D took the temperature of several food items. These deficient practices have the potential to affect 90 of 90 residents who reside in the facility at the time of survey and who receive their meals from the main kitchen. [...]

Inspectors wroteBased upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the second quarter of 2025 (January 1- March 31) was accurate, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 90 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure admission and annual comprehensive Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 6 (R35, R10, R75, R79, R87, and R34) of 8 residents reviewed for late MDS assessments.*R35's admission MDS assessment dated [DATE] was completed after the specified timeframe.*R10's Annual MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.*R75's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.*R79's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.*R87's admission MDS assessment dated [DATE] was completed after the specified timeframe.*R34's [...]

Inspectors wroteBased on interview and record review, the facility did not ensure admission, quarterly, and discharge Minimum Data Set (MDS) assessments were completed and transmitted in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 5 (R102, R35, R79, R87, and R69) of 8 residents reviewed for late MDS assessments.*R102's Discharge Return Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R35's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R79's Discharge Return Anticipated MDS assessment dated [DATE] and R79's Entry tracking record dated 7/11/2025 were not completed or transmitted by the specified timeframe.*R87's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R69's Quarterly MDS assessment dated [DATE] was [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 4 of 4 ( R15, R49, R58, R106) residents residing at the facility whom receive a puree diet.*Cook-D was observed not following a recipe for preparing texture and modified consistency food for puree diets.

Inspectors wroteBased on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R7) of 1 resident reviewed for grievances. * On 7/21/2025, Surveyor interviewed R7, regarding grievances that were reported to staff. R7 indicated reporting concerns with portion sizes of meals to R7's caring partner. R7's meal ticket didn't show double portions. R7 voiced concerns about getting double portions with every meal.

Inspectors wroteBased on interview and record review, the facility did not ensure quarterly Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 1 (R69) of 8 residents reviewed for late MDS assessments.* R69's Quarterly MDS assessment dated [DATE] was completed after the specified timeframe.

Inspectors wroteBased on interview and record review the facility did not revise care plans or complete a care conference for 2 (R61, R9) of 18 residents care plans that were reviewed. *R61 did not have hearing or depression focus areas added to R6's initial care plans. R61’s comprehensive care plan was not completed timely after admission to the facility. *R9 did not have a care conference after the MDS assessment 6/2025.

Inspectors wroteBased on observations, document review, interviews, and facility policy review, the facility failed to ensure proper dishwasher temperature and sanitizer levels, failed to thaw liquid eggs in a safe manner; failed to ensure food in the refrigerator and dry storage was labeled, dated, and not past the use by date; failed to ensure food on the steam table was held at a safe temperature level; and failed to ensure utensils and dishes were clean in one of one kitchen and one of one rehabilitation unit. This had the potential to result in the spread of infections and food born illness for 86 of the 87 residents consuming food in the facility.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure food was served and received at palatable food temperatures for nine of nine residents (Resident (R) R2, R11, R8, R13, R15, R16, R17, R18, and R19) reviewed for palatability of 19 sample residents. This had the potential to result in residents not eating the food and resulting in weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure appropriate door closure with an operating door latch for one of six residents (Resident (R) 4) reviewed for privacy of 12 sample residents. This failure resulted in the potential to affect resident safety, security, and privacy.

Inspectors wroteBased on interviews, record review, and review of the facility policy, the facility failed to ensure a fingerstick blood sugar test (FSBS), and insulin was documented as administered, per the physician's order for one of three residents (Resident (R) 3) reviewed of 12 sample residents. This failure placed the resident at risk for serious medical consequences.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure the Medication Administration Record (MAR) and/or treatment administration record (TAR) was complete and accurate for two of 12 sample residents (Resident (R) 10 and R7) reviewed for accurate documentation. - R10's MARs were not accurately documented to show medications werev administered according to physician orders. -R7's TARs were not accurately completed to show consistent application of ordered treatments to R7's pressure injuries.

Inspectors wroteBased on observations, menu review, and interviews, the facility failed to ensure the menu was followed for all the diets listed on the menu spreadsheet for 81 of 81 residents who receive food from the facility. Failure to follow the spread sheet had the potential to result in weight loss and for residents to feel hungry.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure water temperatures were maintained at safe and comfortable temperatures with the potential for burn-related injuries or for residents to receive showers at uncomfortable temperature levels for three of four units (South unit, North unit, and [NAME] unit) affecting 36 of 81 residents in the facility.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to maintain a functioning call system with auditory alarms to alert staff when a resident called for assistance for one of three call light systems (North station). This could result in residents' needs/care being delayed unnecessarily for the 22 residents in the North Hall.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure there was a physician's order for oxygen therapy for one of two residents (Resident (R) 3) reviewed for oxygen therapy. The lack of physician's orders for oxygen therapy could lead to inappropriate oxygen therapy and medical compromise.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents medications were administered in accordance with their policy for one of three residents (Resident (R) 8) reviewed for medication administration out of 20 sampled residents. Specifically, R8 was ordered to be administered his medications via a gastrostomy tube (g-tube). The resident was administered his medications as a cocktail (administer more than one medication at a time); however, there was no physician order for the medications to be administered as a cocktail. This placed the resident at risk for his G-Tube to become clogged.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 8 (R50, R64, R65, R67, R70, R73, R78 and R235) of 9 residents reviewed for pressure injuries. * R78 developed a stage 4 pressure injury to the right posterior ankle despite the Facility knowing the resident was at risk for pressure injuries because the resident wore PRAFO boots. The Facility failed to perform checks each shift to monitor the skin under the boot to prevent skin issues from developing. The Facility failed to obtain written orders on length of time the PRAFO (contractor/LE (lower extremity) braces) boots should be worn. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that residents received adequate assistance devices to prevent accidents for 2 (R65 and R67) of 7 residents reviewed for accidents. *R65 was transferred using a pivot transfer when R65's Care Plan indicated R65 transferred using a sit-to-stand lift. R65 sustained a broken tibia and fibula. *R67 was observed to not not have a fall mat in place per Care Plan.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 (R65) of 3 residents reviewed with indwelling catheters. *R65 was admitted to the facility with a urinary catheter and the catheter was not removed due to resident convenience with no conversation of risks or benefits documented. R65 was hospitalized [DATE] and 1/6/2024 with sepsis due to a catheter associated urinary tract infection.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that items in the reach in cooler and freezer were dated/labeled according to professional standards and ensure a large silver metal exhaust/vent located above the kitchen dishwasher was in good working condition. These failures had the potential to affect 80 of 81 residents who were served food from the facility kitchen.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure the outside garbage dumpster lids remained closed, and the garbage storage area was maintained in a sanitary condition to prevent the harborage of pests with the potential to affect 81 of 81 residents residing in the facility.

Inspectors wroteBased on observation and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not maintain a system of surveillance, tracking and trending of infections and identifying possible communicable diseases or infections before they can spread to other persons in the facility potentially affecting 81 of 81 residents. ~ The facility had an Infection Control Program that did not accurately track, trend or analyze the infection rate and data to help decrease the rates, numbers and spread of infections in the facility. Line lists did not accurately identify infections in the facility. There was no system of surveillance including maps to identify monthly infections on units. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure dignity was provided for one of eighteen residents (Resident (R) 19) of 39 sampled residents. The facility failed to ensure staff were seated while assisting residents during meals and refrained from calling residents feeders during dining services.

Inspectors wroteBased on record review and interview, the facility did not ensure allegations of mistreatment that resulted in serious bodily injury were reported to the State Agency for 1 (R65) of 2 reportable incidents reviewed. R65 was transferred from the wheelchair to the bed with the assistance of Certified Nursing Assistant (CNA)-X. R65's Care Plan indicated R65 transferred with the use of a sit-to-stand lift. CNA-X did not follow R65's Care Plan and R65 sustained a fractured right tibia and fibula. This incident was not reported to the State Agency.

Inspectors wroteBased on record review and interview, the facility did not ensure Preadmission Screening and Resident Review (PASARR) Level I screens were resubmitted to the State mental health authority after a 30-day exemption had expired and the resident was still in the facility for 1 (R73) of 3 residents reviewed for PASARR compliance. R73 was admitted [DATE]. A PASARR Level I was completed with a 30-day exemption on [DATE]. On [DATE] with R73 was still a resident at the facility, no PASARR Level I was resubmitted.

Inspectors wroteBased on interview, and record review the facility did not revise resident care plans for 2 (R65, R235) of 18 resident care plans reviewed and did not ensure care conferences were held quarterly to get resident input in their care. *R235's care plan was not revised to include showers two times a week as discussed with facility and R235's guardian. R235 did not receive a shower two times a week. *R65 did not have care conferences to ensure participation in the development of a care plan on a quarterly basis.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R70) of 5 residents drug regime was free from unnecessary medications *R70 was admitted to the facility with an order for Eliquis twice daily. The facility did not implement a care plan or orders to monitor for any adverse side effects that could result from taking an anticoagulant.

Inspectors wroteBased on interview and record review the facility did not ensure Residents who receive anti-psychotic drugs were assessed for the potential side effects of the anti-psychotic drugs for 1 (R82) of 5 residents reviewed for unnecessary medications. R82 did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed on 3/22/24 when prescribed anti-psychotic medication.

Inspectors wroteBased on observations, record review, staff and resident interviews and review of facility policy, the facility failed to ensure a comfortable and environment throughout the building. The facility was without adequate linens to ensure resident needs were met, including washcloths, hand towels, and hospital gowns. A total of 19 residents were reviewed in the sample.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure staff prevented accident hazards for 3 (R6, R17, R18) of 3 residents reviewed. after a resident fell out of bed during care, a resident fell during an improper transfer and that two staff transferred a resident when using a mechanical lift for three (Residents (R)6, R17, and R18) out of three residents reviewed for accidents hazards.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to assess the effectiveness of Tylenol for complaints of pain for one of three residents (Resident (R)5.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that the kitchen was maintained in an orderly manner to prepare, distribute, and serve food in accordance with professional standards for food service safety. In addition, the facility failed to ensure that kitchen staff followed proper sanitation procedures to help prevent an outbreak of foodborne illness. This has the potential to affect 83 out of 85 residents in the facility who received an oral diet.

Inspectors wroteBased on interview and record review, the facility did not ensure staff provided basic life support to 1 (R37) of 1 Residents who required Cardiopulmonary Resuscitation (CPR.) The facility currently has 50 out of 92 residents who desire CPR (Full Code.) The failure of staff to immediately call a code for R37 on the overhead page system, failure to call 911, the failure to not start CPR immediately, the failure to bring the crash cart & AED (Automated External Defibrillator) into R37's room during the code, and RN-NN instructing LPN-MM to stop CPR created a finding of immediate jeopardy that began on [DATE]. Administrator-A, DON (Director of Nursing)-B, Corporate Consultant-C, & Regional Clinical of Operations-D were notified of the immediate jeopardy on [DATE] at 12:18 p.m. The immediate jeopardy was removed on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 1 resident (R87) with a significant change in condition had a comprehensive assessment performed. On [DATE] at approximately 5:30 a.m., R87's husband asked RN (Registered Nurse) T for assistance because R87 was not feeling well. RN T did not perform a comprehensive assessment into the change in condition. On [DATE] at approximately 6:00 a.m., R87 became unresponsive, 911 was called, and CPR (cardiopulmonary resuscitation) was initiated. On [DATE], R87 was transferred and admitted into the hospital with a diagnosis of cardiac arrest. R87 subsequently passed away while in the hospital on [DATE]. The facility's failure to perform a comprehensive assessment into a change in condition created a finding of immediate jeopardy that began on [DATE]. [...]

Inspectors wrote2. R68 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, diabetes, dementia with behavioral disturbance, depression, and anxiety. R68's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R68's Brief Interview for Mental Status (BIMS) score was 14 indicting R68 was cognitively intact. R68 was independent for transfers and used a wheelchair for mobility throughout the facility. R68 was not coded as wandering or having behaviors. On 3/7/2021 at 4:23 PM in the progress notes, nursing charted R68 went outside with the smoking residents and tried to open the gate. A wanderguard was placed on R68 at that time. On 3/8/2021, R68's Elopement Risk Care Plan was initiated with the following interventions: -Apply wander guard; monitor function and placement. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to prevent new ulcers from developing for 1 of 6 residents (R56) reviewed for pressure injuries. R56 developed multiple pressure injuries while in the facility with some of them healing. R56 developed a Stage 3 pressure injury to the left clavicle due to the head contracting to the left on 10/20/2022 that was last assessed on 11/15/2022. No weekly assessment was completed on 11/22/22. R56 was hospitalized from [DATE] to 11/28/2022. No documentation was found regarding the left clavicle pressure injury on readmission. On the Skin Integrity Care Plan, the intervention of a neck pillow was initiated on 12/20/2022. [...]

Inspectors wroteBased on interview and review of employee records, the facility did not ensure CNA (Certified Nursing Assistant)/Med Tech-F was qualified to pass medications to residents residing in the Facility after 12/22/22. This has the potential to affect all 92 residents residing in the Facility. CNA/Med Tech-F has a current CNA certificate, was enrolled at [name of] University for diploma in practical nursing and completed pharmalogical for nurses with lab course during the spring semester 2021. CNA/Med Tech-F graduated from [name of] University on 12/22/21. As of 1/25/23, CNA/Med Tech-F did not obtain her LPN (Licensed Practical Nurse) license and has not applied to take the take the med aide challenge exam.

Inspectors wroteBased on observation and interview the Facility did not have bath towels and wash cloths available for personal cares. Multiple observations of the 4 of 4 linen rooms on 1/26/23 revealed no bath towels or wash cloths. The 4 linen rooms were located on the Rehab unit, West, North and South units. The Facility has a census of 92 Residents.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 CNA (Certified Nursing Assistant)-E of 5 randomly selected CNAs had a performance review at least once every 12 months. This deficient practice has the potential to affect those residents whom CNA-E provides care to. A performance review was not completed for CNA-E in 2022.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure medications were disposed of when expired, stored properly, dated when opened in 2 of 2 medication carts and 1 of 2 medication rooms affecting R72, R12, R41, R16, R59, and new admissions to the rehab unit. 1 (R84) of 1 Resident's hospital orders were not transcribed correctly. * R72 glargine insulin vial & R12's lantus pen was not disposed of when expired. * A med cup not labeled containing 10+ white tablets was observed in the South medication cart. * R41's albuteral inhaler was not dated when opened. * R16's albuteral inhaler was not disposed of when expired. * R59's bag of 0.9% sodium chloride 100 ml (milliliters) was expired in the refrigerator located in the Rehab unit medication room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 22 of 23 residents on the [NAME] Unit, 2 (R34 and R84) of 7 residents receiving medication, and 4 (R84, R387, R388, and R389) of 4 residents having blood sugars taken. Observations were made of residents on the [NAME] Unit during mealtimes. No hand hygiene was offered to the residents prior to receiving their meals. * An observation was made during medication pass of R34's Benztropine 0.5 mg tablet and 1 mg tablet being in the nurse's bare hand and then placed into the medication cup. R84's Spironolactone 25 mg tablet was on the medication cart; [...]

Inspectors wroteBased upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order. The laundry is located in a smoke compartment which includes the main entrance area/common area, 1 of 2 dining rooms (east dining room), 2 resident rooms and the kitchen. This deficient practice has the potential to affect those residents who may be in the entrance common area, who may be in the east dining room and the residents residing in the 2 resident rooms. * Surveyor observed 4 of 4 dryers in the laundry room had an accumulation of lint on the wires above the screen and under & in the back of the lint screen which is a potential fire hazard.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R87) of 7 residents reviewed for allegations of abuse reported the allegation to the state agency. On [DATE], R87 had a change in condition, became unresponsive and needed CPR. R87's husband threatened to give R87 antianxiety medications from home if the facility wasn't going to get an order for it. The facility suspected R87's husband may have given R87 some medication prior to R87 becoming unresponsive. The facility called the police to report the suspicion of a crime but did not notify the state agency.

Inspectors wroteBased on interview and record review the Facility did not investigate 2 (R37 & R87) of 7 allegations of mistreatment. * The Facility did not investigate R37's missing gold ring. * The Facility did not investigate an incident involving R87 which occurred on [DATE] that caused the Facility to notify the police.

Inspectors wroteBased on observation, record review and interviews, 3 (R17, R10, R64, R17) of 5 residents reviewed did not receive required assistance with Activities of Daily Living. * On 12/17/22, R17 was hospitalized with diagnoses of COVID and submandibular abscess. The facility could not provide documentation to ensure R17 was getting proper oral hygiene in accordance with R17's plan of care. * R10 did not receive assistance with bathing in accordance with facility protocol. * R64 did not receive assistance with nail care in accordance with facility protocol.

Inspectors wroteBased on record review and staff interviews, that facility did not always ensure that they obtained accurate weights to be able to comprehensively assess 1 out of 9 (R80) residents who were at nutritional risk for weight loss. * A review of R80's weights using multiple methods of obtaining weights reflected R80 had various weight losses and weight gains from one week to another. On 10/30/22 R80 weighed 210 pounds and on 10/30/22 the same date was noted to also weight 269 pounds. R80's weight on 10/30/22 was 269 pounds. On 11/9/22, R80's weight 241.6. On 12/1/22, R80's weight was 230.4 pounds etc. The dietician disputed the weight value with no further follow up. Staff were not consistently using one method to weigh R80. R80's Certified Nursing Assistant (CNA) [NAME] did not indicated in which manner R80 should be weighed. This is evidenced by: Policy Review: [...]

Inspectors wroteBased on interview and record review the Facility did not ensure the physician acted upon recommendations by the pharmacist for 1 (R53) of 2 Residents reviewed with pharmacy recommendations. On 12/20/22 Consultant Pharmacist-Z recommended clarification of indications for use for R53's Risperidone 0.25 mg (milligrams) with directions to give one tablet by mouth one time a day for sleep. This recommendations was not acted upon by the physician and on 1/17/23 Consultant Pharmacist-Z drug regimen report recommended the same clarification.

Inspectors wroteBased on interview and record review, the Facility did not ensure that 1 (R53) of 5 Residents were free from unnecessary drugs. * R53 received Risperidone (Risperdal) 0.25 mg (milligrams) once daily without indications for use.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 32 opportunities which resulted in a medication error rate of 6.25%. Medication errors were identified for R34 & R84. * R34 received the incorrect dose of Sertraline HCL. R34 received 100 mg (milligrams). The physician orders are for 125 mg of Sertraline. * R84 received the incorrect dose of Vitamin B-12. R84 received 200 mcg (micrograms). R84 should have received 500 mcg.