Avina of Sun Prairie

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 15 residents (R8) reviewed for change of condition. R8 was experiencing watery stools and nursing assessments were not performed by the facility. Evidenced by:The facility's Change of Condition policy, dated 1/5/25, states, in part: It is the policy of this facility to promptly identify, evaluate, address, and report a resident's change in condition.3. The nurse will complete a resident evaluation. 4. Phone calls to attending or on-call physicians should be made by the nurse who has collected pertinent information, including the resident's current symptoms and status, onset, duration, severity of the change in condition and available strategies to manage the change of condition in the facility, if appropriate.12. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident who is fed by and received medications by enteral means (also known as tube feeding, as way of sending nutrition and/or medications directly to the stomach or small intestine) receives the appropriate treatment and services for 1 of 1 Resident (R5) reviewed for tube feeding. LPN C administered a water flush and tube feeding without checking placement of R5's gastrostomy tube (a flexible tube inserted through the abdominal wall directly into the stomach, providing a pathway for nutrition, fluids, and medications). Evidenced by:The facility's Verifying Placement of Feeding Tube policy, dated 9/5/25, states, in part: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 3 errors in 29 opportunities that affected 1 out of 4 residents (R4) included in the medication pass task, which resulted in an error rate of 10.34%. R4 received three different eye drops, Latanoprost, Brinzolamide, and Timolol one after another, without any amount of wait time between each different type of eye drop. Evidenced by:Facility policy titled Administration of Eye Drops or Ointments, dated 4/9/2025 states in part: . Eye medications are administered as ordered by the physician and in accordance with professional standards of practice. If a second medication is required in the same eye, wait approximated time per manufacturer's specifications (usually 5 minutes). [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-administer medications for 1 of 1 resident's (R2) reviewed for medication self-administration out of 9 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 40 residents. Surveyor observed frozen drips on the ceiling inside of the facility's walk-in freezer and boxes of unsealed food (under the dripping) to have water damage. Surveyor observed hairlike dust adhered to the electrical cords and piping directly above the food preparation and serving area. Surveyor observed staff washing their hands for a lesser time than the current standards of practice and less than the time outlined by the facility's handwashing policy. Surveyor observed food to be in the facility's main kitchen and in the kitchenette to not have an expiration date, an open date, or a use by date on it. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment for 3 of 15 sampled residents (R30, R14, R24) and 3 supplemental residents (R1, R20, R35). R14, R1, R24, R35, R20, and R30 indicated that the dining room is always cold, and they have to wear a jacket or wrap up in a blanket to stay warm. R30 was observed getting blankets from his room and wrapping it around other residents in the dining room. Resident Council meeting minutes dated 7/19/24, indicated the facility was aware that resident's had concerns of it being too cold in the building. Evidenced by: Facility policy, entitled Environment-Quality of Life, dated 4/2023, with a revision date of 7/3/24, includes in part . [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide food that accommodates resident allergies, intolerances, and preferences or who request a different meal choice for 3 of 15 sampled residents (R3, R17, and R25) out of a total sample of 18 and 1 supplemental resident (R33). Residents were not being served the menu items of their preferences or within parameters of their physician ordered diet, and at times were refused a substitution meal. This is evidenced by: The facility's policy entitled, Meal Identification and Preference Cards/Tickets with no reference date, includes in part: A meal identification and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences . [...]

Inspectors wroteBased on interview and record review the facility did not ensure prompt resolution of all grievances for 2 (R48 and R30) of 15 sampled residents of a total sample of 18. R48 and R30 voiced concerns during individual interviews regarding the facility not following up on voiced concerns/grievances. Staff reported they were aware of concerns voiced by R48 and R30 and reported these concerns to the Grievance Official, who did not follow the facility's grievance process. R48 reported to NHA A (Nursing Home Administrator) multiple times regarding a pair of missing pants. NHA A did not document the grievance on the grievance log and ensure the grievance was resolved. The facility did not ensure prompt resolution of voiced grievances. Evidenced by: The facility's policy, Grievance Guideline, revised 1/27/2017, indicates in part, the following: [...]

Inspectors wroteBased on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 1 residents (R47) reviewed for PIs out of a sample of 18 residents. Pressure Ulcer/Injury R47 was admitted to the facility 3/22/24 with diagnoses including, but not limited to, the following: paraplegia, functional injury at T10-T11 level of thoracic spinal cord, Stage IV right ischial pressure ulcer s/p (status post) excision and flap 2/22/24 with pseudomonas infection/osteomyelitis requiring prolonged course of IV (intravenous) antibiotics, Stage IV sacrococcygeal pressure injury, history of Methicillin Resistant Staphylococcus Aureus infection, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents admitted with mental or psychosocial adjustment difficulties or history of trauma and/or PTSD (Post-Traumatic Stress Disorder) received appropriate person-centered and individualized treatment and services to meet their assessed needs for 2 of 18 sampled residents (R30 & R37). R37 has a diagnosis of PTSD, and his care plan does not address personalized potential triggers or person-centered and individualized treatment and services related to his PTSD. R30 does not have a formal diagnosis of PTSD, however, R30 indicated that he has experienced several traumatic experiences in his past that would indicate symptoms of PTSD. R30's care plan does not address his PTSD symptoms or potential triggers to meet assessed needs related to PTSD. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all injuries of unknown origin/serious bodily injury were reported to the State Agency for 1 of 3 sampled residents (R1) for change of condition. R1 was discovered to have severe bleeding of unknown origin which led to a change of condition and death this was not reported to the State Agency. This is evidenced by: R1 admitted to the facility following a femoral artery bypass surgery and amputation of right foot's digits. R1 had the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that all injuries of unknown origin/serious bodily injury were thoroughly investigated for 1 of 3 sampled residents (R1) for change of condition. R1 had severe bleeding which led to a change of condition and death this was not thoroughly investigated. This is evidenced by: R1 admitted to the facility following a femoral artery bypass surgery and amputation of right foot's digits. R1 had the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility did not maintain medical records on each resident that are complete; accurately documented; readily accessible, and systematically organized for 1 of 3 sampled residents (R1) for change of condition. R1's medical record is missing documentation of his change of condition and subsequent passing away from [DATE]. This is evidenced by: R1 admitted to the facility following a femoral artery bypass surgery and amputation of right foot's digits. R1 had the following diagnoses: [...]

Inspectors wroteBased on observations, interviews, review of facility policy, and document review, it was determined the facility failed to follow the prepared menu for 36 of 39 residents who received a regular diet, a National Dysphagia Diet Level (NDDL) 3, or a NDDL 2 from the facility kitchen. Specifically, the facility failed to serve the correct portion size for vegetables during the lunch meal on 04/25/2023.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility did not ensure that staff treated 19 of 29 residents resident with dignity and respect. Staff were noted to be wearing ear buds (inner ear headphones) to talk on the phone or listen to music while providing care to residents on the South Wing.

Inspectors wroteBased on interviews and record review, it was determined the facility failed to ensure a significant change Minimum Data Set (MDS) was completed within 14 days after hospice services were discontinued for 1 (R4) of 1 sampled resident who received hospice services. R4's hospice services were discontinued on 1/19/23. As of 4/26/23, a significant change MDS had not been completed.