Avina of Milwaukee

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Jul 1, 2024

  Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents (R4, R1, and R3) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. *R4 admitted to the facility on [DATE] and was to have admission lab work completed on [DATE] to get a baseline and because his labs on [DATE] at the hospital had some significant results. The facility did not obtain this lab work until [DATE]. The after hours Nurse Practitioner (NP) was notified of the lab results on [DATE] and ordered a repeat a CBC (complete blood count) on [DATE]. […]

• Immediate jeopardy, isolatedF678Sep 29, 2021

  Based on interview and record review the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation) to residents requiring such emergency care as directed in the physicians orders and the resident's advanced directives for 1 of 10 (R3) residents reviewed for CPR. This failure resulted in R3's death. * On [DATE] R3 was found to be unresponsive, pulseless and not breathing. Facility staff did not call 911 and did not provide CPR to the resident despite her advanced directives which indicated she was to be a full code. Facility failure to perform CPR on R3 created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on [DATE] at 3:55 PM. […]

• Immediate jeopardy, isolatedF684Feb 9, 2021

  Based on interview and record review the facility did not ensure 1 (R3) 1 of residents reviewed received quality of care and treatment when a change in condition occurred while R3 was being transported to/from a medical appointment. The facility did not assess or arrange for a companion during transport despite R3's observed and verbalized anxiety about attending the appointment alone. The facility did not have a clear policy and procedure regarding emergency medical situations during facility transportation, and drivers and dispatch staff were not trained on how to address a medical emergency during transport prior to the incident. […]

• Immediate jeopardy, isolatedF689Feb 9, 2021

  Based on interview and record review the facility did not ensure one (R4) of 3 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. R4 was admitted to the facility following a fall at home with a [MEDICAL CONDITION]. The hospital discharge paperwork sent to the facility on [DATE] referenced R4's frequent falls related to deconditioning and advanced dementia. It continues to document: .Frequent purposeful rounding in place to ensure safety and comfort. (R4) remains impulsive getting up without walker without calling for assistance. (R4) remains on 3L (liters) of O2 (oxygen) via nasal cannula came out of room w/o (without) shirt on and without wearing O2, complaining of not feeling well dizzy. […]

• Actual harm, isolatedF689Aug 12, 2026

  Based on record review, interviews and review of facility policy, the facility failed to provide supervision to prevent accidents for one of three residents reviewed for quality of care (Resident (R) 7). R7 was assessed and care planned to require supervision during meals, meals should be eaten in a dining area, and liquids should be in a cup with a handle and lid. R7 spilled coffee in her lap while eating breakfast in her room without supervision or proper equipment. This failure resulted in R7 sustaining a partial thickness (second-degree) burn to her left thigh. […]