Avina of Mayville

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a Resident (R5) was free from physical abuse by Resident Representative (RR 2). RR2 slapped R5.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 6 of 16 residents (R1, R11, R41, R47, R2, R12) reviewed and for food palatability and 9 supplemental residents (R7, R13, R17, R21, R43, R46, R52, R29, R50). R1, R2, R41, R12, R7, R13, R17, R21, R41, R43, R46, R50, R29, and R52 voiced concerns related to their meals being served at undesirable low temperatures. Resident Representative I indicated R47's hot meal is served cold at times. Surveyors conducted 2 test trays, and the results were not palatable. Evidenced by:Example 1R1 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 54 residents who reside in the facility. Surveyor observed Mighty shakes to be in the refrigerator without a thaw date. Surveyor observed the facility's stove hood to have hair like dust on it above the food cooking surface. Surveyor observed the facility's mixer and meat slicer to be stored unclean. Surveyor observed staff drying dishes with a towel after cleaning and sanitizing them in the 3-compartment sink. Surveyor observed staff wet stacking dishes while observing the dishwashing process. Surveyor observed [NAME] O serving food without donning a hairnet. Evidenced by: Example Mighty ShakesManufacturer's recommendations for use, includes: store frozen. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living for 1 of 16 sampled residents (R28) and 5 of 5 supplemental residents (R16, R25, R26, R49, and R62). Surveyor observed AA J (Activity Assistant) approach R28 from behind in the dining room and pull his wheelchair backwards without warning and move to a different table. Surveyor observed AA J approach R16, R26 and R49 from behind in the dining room and move them to a different spot without talking to the resident and explaining what she was doing. R26, R28, and R49 had a startled look on their face and gripped the chair handles of their wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the resident environment remains as free of accidents/hazards as is possible for 1 of 1 sampled resident (R12) and 1 of 1 supplemental resident (R5) reviewed for accidents/hazards. Surveyor observed R12 sitting in his motorized wheelchair in his room while the chair was plugged into the electrical outlet and charging. The motorized wheelchair has a lithium battery. R12's care plan indicates he can have substances such as beer and cigarettes on the premises and they will be held by nursing staff in a locked area. R12's Nurse Notes indicate R5 entered R12's room and took a beer with him when he exited. While on survey, Surveyor observed R12 to have four 30-packs of beer in his room unsupervised and unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 1 of 3 residents (R28) reviewed for catheters. Surveyor observed R28's indwelling urinary catheter bag to be resting in direct contact with the floor. Evidenced by:Facility policy, titled Catheter Care, implemented 2/1/25, includes: privacy bags will be available and catheter drainage bags will be covered at all times while in use. (It is important to note the policy does not give information on whether it is ok for the catheter bag to be in direct contact with the facility floor.)R28 admitted to the facility on [DATE] with diagnoses, including retention of urine and encounter for attention to other artificial openings of urinary tract. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, this affected 1 of 16 sampled residents (R1). R1 did not receive his ordered nephrocaps (vitamin specific to renal (kidney) support) for several days in November. This is evidenced by: The Facilities Policy and Procedure entitled Medication Administration dated 2/28/25 that does not speak to omitted medications. R1 is a long-term resident of the facility. R1 has the following diagnoses: end stage renal disease, type 1 diabetes mellitus, and dependence on renal dialysis. R1's Physician Orders:Neprhocaps capsule 1 mg (milligram) (B Complex-C-Folic Acid) Give 1 capsule by mouth one time a day for supplement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and 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 infection for 1 of 5 Residents (R2) observed for medication administration, 1 of 1 Residents (R3) observation of wound care, and 1 of 1 observation of equipment disinfection. APNP D (Advance Practice Nurse Practitioner) had breaches in infection control when APNP D did not perform hand hygiene after removal of R3's wound dressings. RN E (Registered Nurse) had a breach in infection control after performing an INR (International Normalized Ratio-a test to determine how long it takes for blood to clot) when RN E did not disinfect the machine prior to bringing the machine out to the nurse's station. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure antibiotics were administered as ordered by the physician for 1 (Resident #23) of 3 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 2 of 6 residents (R) reviewed for abuse (R5 and R6). The facility did not report a resident-to-resident altercation that occurred between R5 and R6. This is evidenced by: The facility policy titled Freedom from Abuse, Neglect, and Exploitation, undated, states in part: It is the policy of this community to take appropriate steps to prevent the occurrence of: Abuse . [...]

Inspectors wroteBased on interview and record review the facility did not develop a comprehensive, person-centered care plan for 1 of 6 sampled residents (R3) reviewed for person-centered care plans. R3 does not have a comprehensive care plan that includes triggers and monitoring targetd behaviors. Evidenced by: Facility policy entitled Comprehensive Care Plans, dated 1/25, states, in part; It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 1 of 2 residents (R2) reviewed for SUDs. R2 has a SUD. The facility failed to create a care plan related to R2's alcohol consumption and failed to implement interventions for behaviors associated with R2's alcohol consumption. This is evidenced by: The facility policy titled Safety for Resident with Substance Use Disorder, dated 1/25, states in part: It is the policy of this facility to create an environment that is as free of accident hazards as possible, for residents with a history of substance use disorder. Definitions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administering of medications was determined to be clinically appropriate for 1 of 1 resident (R3) reviewed for self-administration of medications out of a total sample of 3 residents. Surveyor observed R3 with a large green pill without staff present. The facility did not complete a self-administration of medication assessment on R3, and R3 did not have a physician order for administering her own medications. Evidenced by: The facility's policy, entitled Self-Administration of Medications and Treatments, undated, includes self-administration of medications and treatment are determined by physician order after determining that a resident is able to self-administer. Medications and treatments for self-administration are kept in a locked drawer in the resident's room . [...]

Inspectors wroteBased on interview and record review, the facility did not develop a comprehensive, person-centered care plan for 1 (R3) of 1 resident reviewed for person-centered care plans. R3's care plan states R3 has an active order for anti-anxiety and anti-depressant medication. R3's care plan does not include person-centered, non-pharmacological interventions for anxiety or depression. Evidenced by The facility policy, Comprehensive Care Plans, dated 9/26/22, states, in part; Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan will describe interventions .in order to eliminate triggers . The facility policy, Medication Management, dated10/25/14, states, in part; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure written notification of coverage change, the financial liability for continued stay, and appeal rights were provided to a Resident (R) whose Medicare Part A benefits were ending for 2 (R45 and R7) of 3 residents reviewed for Medicare Part A notifications. The facility did not provide R45 and R7 with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) form, which includes, notification of change in coverage, financial liability, and appeal rights.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 1 (R7) of 2 residents were provided privacy during personal cares. *R7 informed Surveyor staff will leave R7's window drapes open when providing personal cares. R7's window is next to a public patio area and R7 would like R7's privacy when personal cares are provided. *Surveyor observed staff leave the window drapes open while providing cares to R7.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident had a neurological assessment after potential head injury and was comprehensively assessed prior to being transferred to the hospital. This was observed with 1 (R104) of 15 residents reviewed. * R104 had 2 unwitnessed falls without consistent completion of a neurological assessment. * R104 family requested R104 to be transferred to a hospital for evaluation on 7/3/24. There is not documentation of R104 clinical status. or physician order, prior to being transferred to the hospital.

Inspectors wroteBased on record review and interview, the facility did not complete thorough investigations of resident falls, and identify and implement revisions to the plan of care to prevent future falls. This was observed with 1(R104) of 2 residents reviewed with falls. *R104 had falls on 6/29/24, 7/2/24 and twice on 7/3/24. There was no documentation of a comprehensive assessment to determine causative factors. The Facility does not thoroughly investigate F104's falls to determine the root cause nor implement fall prevention interventions based on the identified root cause to prevent future falls.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident's indwelling catheter was medically necessary. This was observed with 1 (R13) of 3 residents reviewed with indwelling catheters. * R13 returned from a hospital stay with an indwelling catheter. There were no medical indications for the use of the catheter and it was not removed for 2 months.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure 1 (R156) of 1 residents reviewed for Dialysis received Dialysis care in accordance with professional standards of practice. *R156 did not have physician's orders for dialysis and there is no evidence staff were assessing and monitoring R156's fistula site on days when R156 did not receive dialysis.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident received a prescribed medication as ordered by the physician. This was observed with 1 (R104) of 6 resident medication reviews. * R104 hospital discharge medication orders were not transcribed correctly upon admission to the facility. R104 did not receive the prescribed medication as directed by the physician.

Inspectors wroteBased on observation, interview, medical record review, and facility policy and procedure review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from developing for 1 resident (R1) of 5 residents reviewed for PI. R1 is at risk for PI development. R1 developed an avoidable, facility acquired, unstageable, medical device related PI to his right scrotum from his Foley catheter. The facility did not determine the root cause of R1's PI until 10/20/23. Subsequently, the facility did not take action to remove the source of the pressure to promote healing and prevent additional pressure until 10/20/23. This is evidenced by: [...]

Inspectors wroteBased on observation, staff and resident interview and record review, the facility did not ensure 1 Resident (R) (R4) of 3 residents reviewed for the use of oxygen therapy received necessary care and treatment. The facility provided R4 with oxygen therapy without a physician's order. R4's use of oxygen therapy was not care planned, assessed, or monitored. In addition, R4's oxygen tubing was not changed timely and the facility did not place no smoking/oxygen in use signage at the entrance to R4's room.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status at the time of the assessment for 3 Residents (R) (R1, R28, and R6) of 18 residents reviewed. R1's MDS assessment, dated 4/26/22, did not accurately reflect R1's mental health status. R28's MDS assessments, dated 1/12/23 and 1/20/22, did not accurately reflect R28's mental health status. R6's MDS assessments, dated 8/2/22 and 11/2/22, did not accurately reflect R6's developmental disability as documented on R6's Preadmission Screen and Resident Review (PASRR) assessment.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not develop and/or implement a comprehensive care plan for 2 Residents (R) (R6 and R49) of 18 residents reviewed. The facility did not develop a comprehensive care plan for R6 and R49 when R6 and R49 were diagnosed with a Multidrug-Resistant Organism (MDRO) and placed on Transmission-Based Precautions (TBP).

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure bathing assistance was provided as indicated for 1 Resident (R) (R10) of 1 resident. R10 voiced a concern with receiving showers. R10's medical record indicated R10 was showered once in the previous 30 days.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure hot and cold beverages were covered for 1 Resident (R) (R28) of 1 resident. In addition, the facility did not assess the ability to safely smoke for 1 (R55) of 1 resident. R28's care plan contained an intervention that indicated R28 drank hot and cold beverages out of a covered mug. That intervention was not consistently implemented and R28 sustained a burn. R55 smoked with the assistance of staff, however, R55 did not have a smoking assessment or care plan related to smoking.