R104 arrived at the facility on June 29, 2024, with a traumatic brain injury and subarachnoid hemorrhage. Within hours, he was on the floor in the hallway. By July 3, his family had seen enough and requested his transfer to a hospital.
The first fall happened at 4:15 PM on his admission day. Staff found R104 in the hallway wearing improper footwear and walking without assistance. Nobody investigated what he was doing when he fell or when staff had last checked on him. The immediate response was to put him in a wheelchair by the nurses' station, then move him to a low bed in his room after dinner.
Three days later, at 3:10 PM on July 2, R104 fell again in his room. This time, activity staff had taken him to use the bathroom and left him alone to find someone to help with toileting. The fall report contained no comprehensive assessment of what led to the incident.
The facility's own care plan, updated that same day, specifically stated "do not leave alone in room." But the daily care instructions printed for staff on August 14 — more than a month later — made no mention of fall risk interventions or the prohibition against leaving R104 unattended.
At noon on July 3, R104 fell from his bed while looking for his brother. Staff had put him to bed just minutes earlier. The response was 15-minute checks and putting him back to bed. No comprehensive assessment was conducted.
Four hours later, at 6:40 AM, R104 fell again with a staff member present. He was walking to the bathroom when he began urinating on the floor. The aide couldn't use a gait belt for assistance, R104's legs became weak, and he collapsed. There was no documented assessment for injury and no immediate interventions related to this fall.
By 11:56 AM that same day, R104's family requested his transfer to the hospital. He never returned to the facility.
The facility's own policy required comprehensive fall investigations and root cause analysis to prevent future incidents. Each fall was supposed to trigger an updated care plan with new interventions communicated to staff. None of this happened.
When inspectors questioned the nursing home administrator about the falls, she provided additional information that wasn't part of the medical record. For the first fall, she said R104 had been toileted at 3:00 PM, was wearing socks, and wasn't using an assistive device. For the second fall, she said activity staff had been re-educated to review care instructions.
But R104's daily care sheet didn't identify him as a fall risk or provide instructions about not leaving him alone. The formal fall prevention plan was marked as "resolved" on July 1 — before three of his four falls even occurred.
The medication errors began immediately. R104's hospital discharge orders prescribed propranolol 10 mg twice daily for tremors. The facility transcribed this as 10 mg once daily for hypertension — wrong dose, wrong frequency, wrong diagnosis.
The error went unnoticed until after R104 had already left the facility. A medication occurrence form dated July 3 noted the mistake was discovered only after his transfer. The assistant director of nursing had supposedly caught the error during a second check of admission orders but thought the correction had been saved in the computer system.
Another patient, R13, returned from a hospital stay in June with an indwelling catheter that remained in place for two months without medical justification. R13 had been hospitalized for sepsis and acute respiratory failure. The hospital had placed the catheter, but no medical diagnosis supported its continued use at the nursing home.
A physician's order on June 4 specified catheter care every shift but provided no medical reason for the device. A bladder assessment completed the same day noted only that R13 "cannot make needs known" and "needs to be checked on regularly."
The director of nursing later told inspectors they kept the catheter "for comfort, and for hospice" care. When R13's condition improved, they removed it. R13 died on hospice care on August 13, never having developed a urinary tract infection during the two months with the unnecessary catheter.
A third patient, R156, needed hemodialysis for end-stage renal disease but had no physician's orders for the treatment. The facility also failed to monitor his arteriovenous fistula on days when he didn't receive dialysis.
R156 had a fistula in his left forearm for dialysis access. The facility's own policy required daily assessment of the site using a stethoscope to check for proper blood flow, with documentation on medication records. Staff were supposed to observe for increased redness or swelling and notify doctors of any problems.
When inspectors reviewed R156's records, they found no physician's orders for dialysis and no documentation of fistula assessments. A registered nurse told inspectors she checked the fistula daily when she worked, and the documentation should be in the medication records. But when she opened the electronic system to show the inspector, she couldn't find any assessments.
The assistant director of nursing said they didn't need an order for dialysis but should have an order to check the fistula site. The director of nursing agreed they needed orders specifying the type and location of the access site and when to document assessments.
Only after inspectors raised these concerns did the facility add proper physician's orders on August 14. The new orders specified pre-dialysis vital signs, blood pressure monitoring on the unaffected arm, and assessment of the fistula site every shift for blood flow and signs of complications.
R156's care plan was also updated that day to include a note about not drawing blood or taking blood pressure measurements from the arm with the dialysis site — a basic precaution that should have been in place from admission.
The inspection found systematic failures in basic patient safety protocols. Fall investigations that never happened. Medication errors that went unnoticed for days. Medical devices used without justification. Critical monitoring that existed only in policy manuals, not in practice.
R104's family made the right decision when they requested his hospital transfer after watching him fall four times in five days. The facility had proven it couldn't keep him safe or even figure out why he kept falling. His traumatic brain injury required careful monitoring and prevention strategies that never materialized during his brief, troubled stay at Avina of Mayville.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina of Mayville from 2024-08-15 including all violations, facility responses, and corrective action plans.