Avina of Kenosha

In the surveyor’s words

From the most serious findings on record at Avina of Kenosha, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 20, 2026

  Based on observations, record review, policy review, and interviews, the facility failed to ensure effective interventions were implemented to prevent 1 of 12 residents who smoked (Resident (R)14) from a sample of 22 residents, from repeatedly smoking inside the facility. A 12/12/25 smoking assessment determined that R14 could smoke outside, in the designated smoking area, unsupervised. Between 01/19/26 and 07/02/26, R14 was found smoking in his room [ROOM NUMBER] times. The facility failed to implement additional interventions after each of these incidents and continued to allow R14 to hold his smoking materials. A 07/13/26 smoking assessment continued to identify R14 as being able to smoke outside unsupervised and added that staff were to keep R14's smoking materials in their possession. […]

• Immediate jeopardy, patternF678Feb 2, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF686Apr 29, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF684Feb 2, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Feb 2, 2023

  Based on observation, record review, and staff interviews, the facility did not always ensure that 3 out of 9 residents (R29, R68, and R72) reviewed for being at risk for elopement and falls were provided with adequate supervision and assistance devices to prevent accidents. The facility did not evaluate and analyze residents' falls and elopement attempts to determine a root cause analysis. The facility did not implement resident centered care plan interventions to reduce future risk of falls and elopements, The facility did not monitor interventions for effectiveness and modify interventions to provide additional supervision to mitigate the risk of another accident/elopement from occurring. […]