Avina of Mayville

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 8, 2023

  Based 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. […]

• Actual harm, isolatedF686Oct 10, 2022

  Based on observation, interview, and record review, the facility did not ensure each resident received care consistent with professional standards of practice to prevent pressure injuries (PIs) from developing for 1 Resident (R) (R1) of 3 sampled residents reviewed for PIs. R1 developed an unstageable pressure injury to the right and left heel after admission to the facility. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 did not receive weekly nursing assessment for the left or right heel pressure injury once identified. R1 did not receive weekly skin checks for prevention of skin breakdown. R2 did not receive weekly skin checks for prevention of skin breakdown. R3 did not receive weekly skin checks for prevention of skin breakdown. […]

• No harm, potential for more than minimal, widespreadF804Dec 4, 2025

  Based 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]. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF550Dec 4, 2025

  Based 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. […]