The incident occurred on January 26, 2025, around noon at Crossroads Care Center of Mayville when Resident 2 had an altercation with Resident 1 and "threatened to kill" the other resident. Staff noted that Resident 2 "had been drinking that morning," according to the facility's own investigation summary.
Federal inspectors found that staff had documented "on many different occasions, empty bottles of alcohol laying around R2's room along with a smell of alcohol coming off R2." Despite this pattern, the facility never developed interventions to address his alcohol abuse or the behaviors that accompanied his drinking.
Resident 2 was admitted to the facility with diagnoses including alcohol abuse, repeated falls, and unsteadiness on his feet. His physician orders contained no authorization for him to consume alcoholic beverages.
The incidents escalated throughout the winter. On December 26, 2024, nurses documented that the resident "appears to be intoxicated, smells of alcohol and slurring words. He was in the dining room arguing with other resident and family."
Three weeks later, his drinking led to a fall. On January 17, 2025, at 11:31 PM, a nurse was called to his room after he fell. When staff arrived, "resident was getting up and trying to get into the bed. He had one shoe on and one shoe off with a regular sock on the other foot. This was making his foot slip."
The nurse noted his blood pressure was low "due to him being intoxicated" while his other vital signs remained normal. The resident said his pride was the only thing hurt.
Two days later, despite freezing temperatures and administrative orders that no residents should go outside, Resident 2 "refused to stay inside stating it's not that cold. Resident made multiple trips outside to smoke and went to Kwik Trip."
When inspectors interviewed Registered Nurse D about the resident's behaviors, she said he "likes to talk like he's tough and will make sexual comments to the staff."
The facility had a comprehensive policy for residents with substance use disorders. The policy required staff to assess risks, implement care plan interventions including "increased monitoring and supervision," and provide "appropriate diversions for resident." It called for behavioral health services, medication-assisted treatment, and working with families to address treatment goals.
None of this happened for Resident 2.
His care plan, dated February 21, 2025, contained only a single focus area about leisure pursuits. The goal was for him to "make one positive statement about his leisure pursuits to staff weekly." Interventions included encouraging him to pursue leisure interests and providing him with an activity calendar.
The care plan made no mention of his alcohol abuse diagnosis. It contained no triggers related to substance use, no goals for addressing his drinking, and no interventions to prevent alcohol consumption or mitigate associated risks.
When inspectors interviewed Social Services Designee E about the resident's care plan, she acknowledged that "R2's substance use, behaviors and interventions should be on the care plan." She confirmed there should be monitoring and intervention for his substance use and associated behaviors, but said "R2 does not have a care plan related to substance use or behaviors."
Director of Nursing B gave the same assessment. She told inspectors that Resident 2 "should have a care plan for his substance use and associated behaviors but does not."
The facility's medication and treatment records for January and February 2025 showed no monitoring of behaviors or substance use, despite the documented incidents of intoxication and threatening behavior.
Meanwhile, another resident faced a different but equally serious gap in care planning. Resident 3, who had dementia and anxiety disorders, displayed increasingly aggressive behavior toward staff that was never addressed in her comprehensive care plan.
The 12 out of 15 score on her Brief Interview of Mental Status indicated mild cognitive impairment. Her diagnoses included dementia with psychotic disturbance, anxiety disorder, and major depressive disorder.
Her care plan focused on general psychosocial well-being and medication monitoring. It included interventions like "encourage the resident to express her thoughts and feelings" and "help the resident feel welcome, accepted, acknowledge and well-received."
What it didn't include were the specific aggressive behaviors staff documented repeatedly in her progress notes.
On October 1, 2024, during a shower, the resident "called CNA a bitch several times and hit CNA in her right arm x2." Staff completed the shower with no further issues.
By November, her aggression had expanded to medication refusal. A November 24 note described how she "continues to refuse medications in the morning in an aggressive way. She never just states that she does not want it. She yells, sometimes swears, sometimes demands staff to get out."
The behavior affected multiple shifts and prevented her from receiving important medications. Staff noted she was developing Parkinson's-like tremors, possibly from missed doses. When they brought this to her attention, "she always states to me BULLS*** several times."
She also refused to be turned for wound care on her coccyx and sacrum.
The aggressive incidents continued into December. On December 3, she "refuses shower after three attempts by three different people" and "started to raise her voice and become extremely agitated after final attempt."
By December 21, her nighttime behaviors had intensified. She was "pushing the call light continuous at times stating that she is sinking" and slapped a CNA who came to check on her. Staff noted "she has been getting more and more physical with the staff regarding cares."
The pattern persisted through February. On February 21, 2025, while receiving care, she "tried to kick the CNA a couple of times while changing her." When asked not to do that, she responded, "I can if I want to."
Staff had developed informal strategies to manage her behavior. Certified Nursing Assistant G said she would "reapproach, not push her, and back off." Registered Nurse D used "redirection or distraction" and would have two staff members provide care together when the resident was agitated.
CNA H offered the resident "food, drink, or tries to change the subject to distract her," noting that the resident liked hot chocolate and various snacks. Staff also recognized that she became more agitated when her husband left after his twice-daily visits.
These interventions worked to some degree. Several staff members said they had not personally experienced aggression from Resident 3, though they were aware of incidents with other caregivers.
But none of these triggers, behaviors, or successful interventions appeared in her care plan. When inspectors asked CNA H if the behaviors or interventions were written down anywhere for staff reference, she said "staff just know what triggers R3 and what can calm her down."
Director of Nursing B confirmed that resident behaviors should be listed on care plans, and that staff would receive information about behaviors through shift-to-shift reports. But she also confirmed that behaviors were not included on the CNA Kardex, a key reference document for direct care staff.
The inspection found that both residents' care plans failed to meet federal requirements for comprehensive, person-centered care that addresses all identified needs with measurable objectives and timeframes. For Resident 2, this meant no intervention for a substance use disorder that led to threats of violence. For Resident 3, it meant no systematic approach to managing aggressive behaviors that interfered with essential medical care.
Both residents remained at the facility as of the February 21, 2025 inspection, their underlying conditions unaddressed by formal care planning despite months of documented incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina of Mayville from 2025-02-21 including all violations, facility responses, and corrective action plans.