Avina of Weyauwega: Mental Health Care Failures - WI
The diagnosis didn't appear on the facility's diagnosis list. It wasn't included in the care plan. The behavior assessment completed at admission rated the resident as a minimal risk for aggression, with no similar assessment done again during the entire stay. The safety plan the psychiatric provider had created never made it into the resident's medical record at all.
The inspection, conducted August 27, 2025 in response to a complaint, reviewed the records of this resident, identified as R2, and found a pattern of missed steps, unanswered questions, and undocumented calls stretching across two months.
On June 30, a nurse practitioner saw R2 and noted the resident was waking up with flashbacks, crying, and hearing voices. The note said nursing staff would follow up with R2's outside psychiatric provider. R2's medical record contained no evidence that anyone did.
R2 was hospitalized for medical reasons in early July. When the resident was discharged on July 11, hospital documentation included a referral for a neuropsychological evaluation. No appointment was made.
By July 16, the nurse practitioner's notes finally named what the admission paperwork had said from the start: paranoid schizophrenia, PTSD, and psychogenic syncope. The note said the provider would ensure R2 had psychiatric follow-up and recommended contacting a hospital for the neuropsych evaluation. The record showed no follow-through.
Then, on August 3, R2 hit their head against a wall hard enough to reopen a forehead abrasion. Two days later, nursing staff redirected R2 during another self-harm attempt. On August 6, the nurse practitioner noted that R2's psychiatric status remained "a significant concern" and said staff would contact R2's outside psychiatric provider again for a plan of care. R2's medical record contained no progress note, no new orders, and no psychotherapy update following that entry.
When the surveyor interviewed the Regional Director of Operations and the Assistant Director of Nursing on August 26, the explanations came in pieces. The Assistant Director of Nursing said the admission and MDS nurse had missed the schizophrenia diagnosis when R2 arrived. The Regional Director of Operations said that if the diagnosis had been recognized, it would have been properly assessed and care planned. Both confirmed that care plan updates and assessments were not completed after R2's behavioral concerns emerged.
The Assistant Director of Nursing said the facility had received the paperwork containing the paranoid schizophrenia diagnosis but did not communicate it correctly or care plan for it to ensure R2 received appropriate care. She said calls had been made to R2's outside psychiatric provider but could not confirm whether anyone had ever asked for the safety plan or sought collaboration on R2's care, because none of those contact attempts were documented.
On the neuropsych evaluation, the explanation was that R2's outside psychiatric provider needed to pre-approve the evaluation for insurance payment to occur. Multiple calls had been made to follow up on that approval, the Assistant Director of Nursing said, but return calls weren't received. She confirmed that staff had not documented any of those attempts. The Regional Director of Operations confirmed the evaluation was never scheduled and never happened.
A resident arrived carrying documentation of a serious psychiatric history, with a safety plan already written and a record of needing constant supervision. Two months later, after two self-harm incidents, the evaluation recommended at hospital discharge still hadn't been scheduled, the care plan still hadn't been updated, and no one could say with certainty whether the psychiatric provider coordinating that resident's care had ever been meaningfully reached.
The facility's own notes described R2's psychiatric status as a significant concern on August 6. The inspection was opened three weeks later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina of Weyauwega from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
Avina of Weyauwega in Weyauwega, WI was cited for violations during a health inspection on August 27, 2025.
The diagnosis didn't appear on the facility's diagnosis list.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.