Avina on Division

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all of the 31 residents residing in the facility. The facility's Water Management Plan (WMP) did not include water management team members who were knowledgeable about the facility's high-risk plumbing fixtures, identify all locations where Legionella could grow and spread, or identify where control measures should be applied based on where Legionella could grow and spread.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure a sanitary, comfortable, and home-like environment for 6 residents (R) (R7, R8, R4, R9, R6, and R5) of 6 sampled residents. R7's shared bathroom contained a walk-in shower that contained a tan/gray/green chalky substance and a cardboard box of personal belongings that were scattered on the shower floor. An unmarked plastic cup of green, cylindrical pellets was set on an area that surrounded the top of the shower. R7's room also contained brown discoloration in the corner of the ceiling and a deteriorating area that contained water damaged plaster and trim that measured approximately 5 inches by 5 inches behind the door in the interior corner of the room. R8's room contained brown discoloration in the corner of the ceiling. R4 and R9's shared bathroom contained a walk-in shower. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provde the appropriate care and treatment to promote healing of a pressure injury for 1 resident (R) (R3) of 1 sampled resident. R3 had a stage 4 pressure injury on right lateral lumbar region. During wound care, Licensed Practical Nurse (LPN)-D used soiled scissors to cut silver alginate that was applied to R3's pressure injury. In addition, LPN-D opened a 4x4 gauze package, removed the gauze, and sprayed it with wound cleanser. LPN-D placed the wet gauze on the outside of the gauze package that had touched soiled surfaces.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure parenteral medications were administered in accordance with a physician order for 1 resident (R) (R2) of 1 sampled resident. Licensed Practical Nurse (LPN)-D administered two intravenous (IV) normal saline (NS) flushes through a midline catheter for R2 who did not have an order for the flushes. In addition, R2's midline catheter was not accurately measured by Director of Nursing (DON)-B or reflected in R2's medical record.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to employ a Registered Nurse (RN) ensuring the minimum requirement of having an RN providing services at least eight consecutive hours a day, seven days a week and failed to employ an RN who was designated to serve as the Director of Nursing (DON) on a full-time basis. These failures caused the facility's nursing staff department to have no oversight of Licensed Practical Nurses (LPNs) and non-licensed personnel (Certified Medication Aide/Medication Technician [CMA/MTs]) who administered medications which placed all residents at risk of not being able to attain or maintain their highest practical physical, mental, and psychosocial well-being. This had the potential to affect 34 of 34 residents who resided at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct an assessment for a patient-reported change in condition for one of five residents (Resident (R) 2) reviewed for change in condition. On 02/17/26, R2 complained to Licensed Practical Nurse (LPN) 1 that she might need to go to the hospital. LPN1 did not immediately assess the resident to determine if R2 had an emergent need after R2 reported respiratory symptoms. This resulted in R2's Family Member (F1) calling 911. R2 was transferred to the hospital and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli (PE) without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. Findings Include:According to BOARD OF NURSING N 6.03 Chapter N 6 STANDARDS OF PRACTICE FOR REGISTERED NURSES AND LICENSED PRACTICAL NURSES> N 6.04 Standards of practice for licensed practical nurses. [...]

Inspectors wroteBased on interviews and record review, the facility failed to have an effective system in place to ensure residents were free from significant medication errors for 1 of 5 sampled residents (R2). R2's infectious disease doctor ordered two oral antibiotics on 01/15/26 upon completion of an intravenous (IV) antibiotic for discitis osteomyelitis (a serious spinal infection affecting vertebrae and intervertebral discs, characterized by severe, persistent back pain). The facility did not transcribe the order or administer the antibiotics until after R2 was sent to the emergency room (ER) with redevelopment of previously cleared osteomyelitis. Additionally, R2 was intravenously administered another resident's antibiotic on 01/13/26. Review of the facility's policy titled, Medication Errors, dated 2025, revealed, Policy: [...]

Inspectors wroteBased on interview and record review including review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) report, review of the documented narrative from the local police department's body-worn camera, review of job descriptions, review of facility policies and procedures, and facility document review, the facility failed to ensure sufficient nurse staffing was available to meet the immediate care needs of the residents, failed to ensure staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, and failed to ensure Licensed Practical Nurses (LPNs) and Certified Medication Aides/Medication Technicians (CMAs/MTs) provided services that met professional standards of practice. These deficient practices had the potential to affect all 34 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure expired food was discarded and the kitchen was maintained in a clean and sanitary manner. These failures placed 34 of 34 residents who resided at the facility at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review of the facility's Administrator's Job Description, the Administrator failed to administer the facility in a manner that ensured a Director of Nursing (DON) and/or a Registered Nurse (RN) was employed to provide oversight of nursing staff that enabled the facility to attain and maintain the highest practicable care and well-being of each resident. The lack of nursing oversight due to the Administrator's decisions caused or is likely to cause serious injury, harm, impairment, or death to residents. Administration was aware the facility did not have a qualified Director Nursing overseeing resident care since 3/13/26. Administration was aware there was not an RN in the building for a minimum of 8 hours a day, 7 days a week. [...]

Inspectors wroteBased on interview, record review, review of the local police department's body worn camera (BWC) report, and policy review, the facility failed to ensure one of five sampled residents (Resident (R) 2) was treated with dignity related to toileting needs. R2 was care planned to use the toilet; however, staff used a bedpan and/or incontinence pad. This caused R2 to feel discomfort and embarrassment.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure kitchen equipment and dishware used to serve residents were free from residue accumulation. This practice had the potential to affect all of the 33 residents residing in the facility. Kitchen equipment and dishware used to serve residents contained visible white residue that made it difficult to tell if the equipment and dishware were clean.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all of the 33 residents residing in the facility. The garbage containers outside the facility were not covered and contained loose/unbagged garbage.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 33 residents residing in the facility. R17 was on contact precautions. On 5/19/25, Licensed Practical Nurse (LPN)-K twice entered R17's room and administered medication without wearing the appropriate personal protective equipment (PPE). On 5/19/25, Laundry Aide (LA)-C transported uncovered clean clothes in hallways and delivered them to residents' rooms. On 5/20/25, LA-C wheeled a cart of clean linens from the clean side of the laundry room through the dirty side and into the housekeeping closet. In addition, a soiled linen hamper was observed in the clean area of the laundry room.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R17) of 15 sampled residents. On 5/20/25, R17's call light was out of reach and not accessible to R17.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 2 residents (R) (R8 and R11) of 15 sampled residents. On 5/19/25, Surveyor observed medication at R8's bedside hours after the morning medication pass. Staff did not return and check on R8 to ensure the medication was taken but documented the medication as administered. In addition, R8 did not have a quarterly self-administration of medication assessment. On 5/19/25, Surveyor observed Medication Technician (MT)-E prepare mediation for R11 and leave the medication at the bedside. R11 had an order to self-administer medication but did not have a current self-administration of medication assessment.

Inspectors wroteBased on observation and staff interview, the facility did not ensure garbage and refuse were properly disposed of in outside garbage storage receptacles. This practice had the potential to affect all 32 residents residing in the facility. The facility's outside garbage receptacles were open on 11/18/24 and were routinely left open during the AM shift.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 31 residents residing in the facility. Dietary Manager (DM)-D did not complete an approved dietary manager or food service manager certification course or other related education.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 31 residents residing in the facility. The ice machine contained black slime on the back inside filter. Two microwaves contained dried food debris. The freezer in the solarium did not contain a thermometer and a temperature log was not maintained. Multiple food items did not contain open or use-by dates. Logs that contained parts per million (PPM) testing of the sanitizer buckets were not maintained.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 4 Residents (R) (R24, R26, R5, and R133) of 5 sampled residents. R24 was admitted to the facility with a diagnosis of spastic diplegic cerebral palsy. R24's PASRR Level I Screen did not indicate R24 had a suspected intellectual disability/developmental disability (ID/DD). The facility did not obtain county exemption for R24's admission and the facility was unable to provide documentation that R24 was referred for a PASRR Level II Screen. R26's PASRR Level I Screen was not completed timely and a county exemption was not obtained. R5's PASRR Level I Screen indicated R5 had a mental illness (MI) and received medications to treat the symptoms/behaviors of the MI. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the wishes of 2 Residents (R) (R23 and R25) of 14 residents were followed when they admitted R23 and R25 whose Power of Attorney for Healthcare (POAHC) paperwork indicated R23 and R25 did not want to be admitted to a nursing home. R23 had an activated POAHC prior to admission to the facility on 3/13/23. R23's POAHC paperwork indicated R23 did not want R23's POAHC to admit R23 to a nursing home. R25 had an activated POAHC prior to admission to the facility on [DATE]. R25's POAHC paperwork indicated R25 did not want R25's POAHC to admit R25 to a nursing home.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician and Power of Attorney for Healthcare (POAHC) were notified of a change in condition for 1 Resident (R) (R25) of 14 sampled residents. R25's physician and POAHC were not notified when staff observed a bump and bruise on R25's head on 2/26/24.

Inspectors wroteBased on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments correctly for 2 Residents (R) (R23 and R24) of 14 sampled residents. R23's MDS assessment, dated 3/19/24, did not indicate R23 smoked. R24 had a physician order for continuous positive airway pressure (CPAP) therapy. R24's MDS assessment, dated 2/11/24, did not indicate R24 used a CPAP machine.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure smoking materials were safely stored for 1 Resident (R) (R23) of 2 residents. R23's care plan indicated staff should store R23's smoking materials when not in use. On multiple occasions from 3/25/24 through 3/26/24, Surveyor observed cigarettes and a lighter on R23's bedside table.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R11) of 2 residents received the necessary care and services for respiratory therapy. The facility provided R11 with respiratory therapy via continuous positive airway pressure (CPAP) without a physician's order. In addition, R11's need for and use of CPAP therapy was not care planned, assessed, or monitored.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure food preferences were honored for 1 Resident (R) (R4) of 14 sampled residents. R4's meal card stated NO GRAVY and no mashed potatoes. On 3/26/24, R4 was served mashed potatoes with gravy for lunch.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a medical record contained accurate and complete information for 1 Resident (R) (R25) of 14 sampled residents. On 2/26/24, staff discovered a bump and bruise on R25's head. R25's medical record did not contain information regarding the injury.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain and infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R8) of 2 residents observed during the provision of care. During an observation of peri and Foley care for R8, CNA (Certified Nursing Assistant)-G did not appropriately remove gloves and cleanse hands.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the posted daily nurse staffing data was retained for a minimum of 18 months. This practice had the potential to affect all residents residing in the facility. The facility did not retain daily nurse staffing data for the required minimum 18 months.

Inspectors wroteBased on record review and staff interview, the facility did not ensure a Registered Nurse (RN) worked at the facility for at least eight consecutive hours per day, seven days per week on multiple dates from April of 2022 to March of 2023. The facility did not have an RN in the facility for at least eight consecutive hours on multiple days and weekends dating back to April of 2022.

Inspectors wroteBased on staff interview and resident interview, and record review, the facility did not ensure a written notification of transfer was provided for 4 Residents (R) (R188, R14, R3, and R20) of 4 residents reviewed for transfer notification. The facility did not provide written notification of transfer, including advocacy information, to R188, R14, R3, and R20 (or their representatives) when transferring care responsibilities to the hospital.

Inspectors wrote4. On 3/5/23 at 10:52 AM, Surveyor entered R8's room and observed a charger connected to an outlet in the room. R8 stated the charger was for a motorized scooter and verified the motorized scooter was always charged in R8's room. See interview under example 2. Based on observation, resident and staff interview, and record review, the facility did not ensure the safety of 4 Residents (R) (R14, R17, R18 and R8) of 6 residents reviewed for accidents and hazards related to motorized scooters, smoking and unwitnessed falls. The facility did not complete neurological checks to monitor for nervous system issues after R14's unwitnessed falls. The facility did not charge R17's motorized scooter in an area to minimize damage from risk of fire. The facility did not provide supervision per R18's assessment and care plan or ensure R18's smoking materials were stored safely when not in use. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored under sanitary conditions. This practice had the potential to affect multiple residents, including R11 and R12. In November 2022, staff stopped monitoring the temperature of a refrigerator and freezer that contained resident food and beverages. Staff did not apply dating practices to opened time and temperature controlled foods for safety. Staff did not discard expired foods and beverages, including items labeled for R11 and R12.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a legal guardian exercised rights within the limits set by Wisconsin (WI) state statute chapter 55 for 3 Residents (R) (R14, R27, and R4) of 6 sampled residents. The facility did not file a petition for protective placement for R14, who had a legal guardian, when R14's stay at the facility exceeded 60 days from admission on [DATE]. The facility did not file a petition for protective placement for R27, who had a legal guardian, when R27's stay at the facility exceeded 60 days from admission on [DATE]. The facility did not ensure R4's protective placement was annually reviewed by the county department and deemed appropriate.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a legal guardian was provided written notification of a payer source change with appeal rights information in the recipient's preferred language when Medicare Part A benefits ended for 1 Resident (R) (R27) of 3 residents reviewed for advanced beneficiary notifications. The facility did not provide R27's legal guardian (Legal Guardian (LG)-E) with written notification in R27 and LG-E's preferred language (Spanish) and a professional translator to explain the information verbally when presented via telephone.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure written notification of the facility's bed-hold policy was provided for 2 Residents (R) (R188 and R14) of 4 residents reviewed for bed-hold policy notification. The facility did not provide written notification of the bed hold policy to R188 when the facility transferred R188's care to Hospital-R. The facility did not provide written notification of the bed hold policy to Legal Guardian (LG)-D when the facility transferred R14's care to a local. hospital. 1. On 3/5/23, Surveyor reviewed R188's closed medical record which indicated R188 was transferred to the hospital on 2/14/23. R188's medical record did not contain a written bed-hold notification. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R20) of 5 sampled residents met the Pre-admission Screen and Resident Review (PASRR) requirements. R20's Level 1 PASRR documented R20 had a current diagnosis of a major mental disorder. No further PASRR screens were completed for R20.

Inspectors wroteBased on staff interview, and record review, the facility did not ensure activities were designed and provided to meet interests for 1 Resident (R) (R14) of 1 resident reviewed for activities. The facility did not comprehensively assess, care plan, and provide activities for R14 since R14's admission on [DATE].

Inspectors wroteBased on staff interview and record review, the facility did not ensure treatment and care were provided in accordance with professional standards of practice for 2 Resident (R) (R11 and R24) of 3 sampled residents reviewed for weight monitoring. R11 had an order for daily weights and to update the physician with weight changes of plus or minus 3 pounds per day or plus or minus 5 pounds per week. The facility did not consistently monitor R11's weight and/or notify R11's physician of weight changes. R24 had an order for monthly weights. The facility did not consistently monitor R24's weight on a monthly basis.

Inspectors wroteBased on staff interview and record review, the facility did not ensure creation of a culturally competent, trauma-informed care plan for 1 Resident (R) (R14) of 1 resident with an identified trauma history and assessed as having intermittent issues with coping and functioning related to surviving trauma. The facility did not develop a trauma-informed care plan after assessing R14 as a trauma survivor on 10/27/22.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R14) of 3 residents reviewed for behavioral health with a diagnosed mental health disorder and trauma history was provided with a Medical Doctor (MD) ordered psychiatric consult. The facility did not obtain a psychiatric consult for R14 after an MD ordered the consult on 9/14/22.

Inspectors wroteBased on staff interview and record review, the facility did not ensure behavioral interventions and psychotropic medication monitoring was implemented for 1 Resident (R) (R14) of 5 residents reviewed for medications. The facility did not develop R14's psychotropic medication care plan, identify target behaviors, develop non-pharmacological interventions, or implement monitoring for target behaviors and medication side effects.