Avina on Division

In the surveyor’s words

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

• Immediate jeopardy, widespreadF727Mar 28, 2026

  Based 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. […]

• Actual harm, isolatedF684Mar 28, 2026

  Based 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. […]

• Actual harm, isolatedF760Mar 28, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Mar 28, 2026

  Based 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. […]