Avina of Weyauwega

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 17, 2025

  Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R19 and R27) of 5 sampled residents which had the potential to affect more than 4 of the 49 residents residing in the facility, including 3 residents who shared a bathroom with R19. The facility did not ensure R19 smoked cigarettes in a safe manner consistent with the facility's smoking policy. R19 smoked in R19's room with no revisions to R19's care plan to ensure the safety of R19 or other residents in the vicinity. On one occasion, a hot cigarette butt had singed trash in a garbage can in R19's bathroom. R27 exited the building unsupervised on multiple occasions. […]

• Immediate jeopardy, isolatedF760Apr 17, 2025

  Based on resident and staff interview and record review, the facility did not ensure 3 residents (R) (R203, R24, and R300) of 3 residents reviewed for intravenous (IV) medication were free of significant medication errors. R203 was admitted to the facility on [DATE] with an order for IV antibiotics twice daily after a 42 day admission to the hospital for multiple infections and septic shock. Staff did not initially recognize a dosing error in R203's hospital discharge order for cefepime and entered the order incorrectly. On [DATE], Registered Nurse (RN)-P changed the order without consulting with a physician. Staff did not follow the IV medication order by the discharge physician or the facility's admitting physician. […]

• Immediate jeopardy, isolatedF684Jul 24, 2024

  Based on staff interview and record review, the facility did not ensure appropriate care and treatment was provided consistent with N6 Wisconsin Nurse Practice Act when 1 resident (R) (R2) of 9 sampled residents experienced a change of condition. On 5/16/24, R2 experienced a change of condition and indicated to staff that R2 was having difficulty breathing and felt like R2 was having a stroke. Certified Nursing Assistant (CNA)-D and CNA-J reported R2's change of condition to nursing staff on 5/16/24. Registered Nurse (RN)-C and Licensed Practical Nurse (LPN)-K did not adequately assess R2 or report R2's concerns to a physician. In addition, R2's change of condition was not reported to night shift staff on 5/16/24. […]

• Immediate jeopardy, isolatedF580Mar 11, 2021

  Based on record review and staff interview, the facility did not notify the physician of changes in resident condition in a timely manner that may have altered treatment for 1 Resident (R) (R73) of 21 sampled residents R73 was admitted to the facility with multiple comorbidities on 1/8/21. R73 exhibited potential symptoms of COVID-19 and a change in condition on 2/1/21. The physician/nurse practitioner was not notified of R73's change of condition for medical intervention. R73 was found in respiratory distress and sent to the hospital on 2/2/21 where R73 was diagnosed with COVID-19. R73 passed away at hospital on 2/4/21. […]

• Immediate jeopardy, isolatedF684Mar 11, 2021

  Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practical well-being for 1 Resident (R) (R73) of 21 sampled residents and did not provide care consistent with professional standards of practice (N6, Nurse Practice Act, Wisconsin). R73 was admitted to the facility with multiple comorbidities on 1/8/21, making R73 at increased risk for severe illness from COVID-19. R73 exhibited potential symptoms of COVID-19 infection on 1/31/21 and 2/1/21 and did not have a thorough physical assessment completed. R73's condition deteriorated and R73 was later found in respiratory distress. R73 was sent to the hospital on 2/2/21 where R73 subsequently tested positive for COVID-19. R73 passed away at the hospital on 2/4/21. […]