Avina of Weyauwega: Care Plan Failures After Drug Screens - WI
The inspection, completed on August 27, 2025, was a complaint survey. It identified deficiencies related to care planning for two residents — identified in the report as R6 and R7 — both of whom had tested presumptive positive for substances, and neither of whom had care plans that reflected what the facility's own policy required after such a finding.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. But the gap it exposed was specific and verifiable: the facility knew about both positive screens, had an internal policy about what to do, and then did not document that policy in the care plans of the residents it applied to.
R7's situation is laid out in the most detail in the inspection record. The resident was admitted to the facility on a date the report does not specify and carried a cluster of diagnoses that included dementia, Wernicke's encephalopathy, alcohol dependence, fatty liver disease, and depression. Wernicke's encephalopathy is a brain disorder caused by vitamin B1 deficiency and is commonly associated with chronic alcohol abuse.
A cognitive assessment completed on August 13, 2025, gave R7 a BIMS score of 11 out of 15, placing the resident in the range of moderately impaired cognition. R7 had a legal guardian responsible for healthcare decisions.
On July 5, 2025, a urine drug screen came back presumptive positive for THC.
R7's care plan, dated April 1, 2025, already addressed the resident's history of substance abuse. Interventions added on April 7 included encouraging R7 to express thoughts and feelings, encouraging the resident to follow physician orders, monitoring for signs that R7 was drinking, instructing R7 that drinking is against facility policy and could lead to involuntary discharge, monitoring for behavioral changes, and notifying the physician and social services of any changes.
The care plan did not include monitoring for the presence of illegal drug use. It did not include a directive to notify the nursing home administrator if illegal drug use was observed so law enforcement could be contacted. Both of those things were required under the facility's own policy. After the July 5 positive screen, the care plan was not updated to add them.
The inspector reviewed R7's record between August 25 and August 27, more than seven weeks after the positive drug screen.
R6's record contained a similar gap. That resident also had a presumptive positive urine drug screen, on May 27, 2025. The care plan for R6 likewise did not include monitoring for illegal drug use and did not direct staff to notify the administrator so law enforcement could be called. The report does not describe R6's diagnoses or cognitive status in detail, but the pattern was the same: a positive screen, an existing care plan that addressed some aspects of the resident's substance-related history, and no update after the test result came in.
By August 27, nearly three months had passed since R6's positive screen.
On the afternoon of August 27, the inspector interviewed the Regional Director of Operations, identified in the report as RDO-C. The director confirmed that both care plans should have been updated. R6 and R7's plans, the director said, should have included monitoring for the presence of illegal drug use and a directive to notify the nursing home administrator if it was observed, so law enforcement could be notified per facility policy.
That confirmation closed the loop on what the inspection found: this was not a dispute about whether the policy existed or whether it applied. The facility's own regional director agreed it should have been followed and wasn't.
Care plans are not incidental paperwork. For residents living with conditions like dementia and alcohol dependence, a care plan is the document that tells staff, on any given shift, what to watch for, who to call, and what to do. A resident like R7, with moderately impaired cognition and a guardian making healthcare decisions on their behalf, depends on that plan being current and accurate. If a staff member on a night shift sees something concerning and the care plan doesn't tell them to notify the administrator, they may not. If the plan doesn't say law enforcement can be contacted, that call may not happen.
The facility had the information it needed. The positive screens were in the medical records. The policy about what to do next existed. What didn't happen was the step of putting those two things together in the documents that govern daily care.
The inspection report does not say whether either resident was found with illegal substances after the positive screens. It does not say whether staff observed any concerning behaviors in the months between the drug test results and the inspection. It does not say whether the guardian for R7 was notified of the positive THC screen or what follow-up, if any, occurred with the physician. The report addresses only what the care plans contained and what they were missing.
What it establishes is that the gap was not brief. For R6, it lasted from late May through late August. For R7, from early July through late August. During that time, staff working with both residents were operating without care plans that reflected the full picture of what the facility knew and what its own policy required in response.
The Regional Director of Operations did not dispute any of it.
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 inspection, completed on August 27, 2025, was a complaint survey.
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.