Avina of Kenosha: Resident Falls After Safety Device Skipped - WI
The resident, identified in inspection records only as R3, fell on August 30 at Avina of Kenosha. A certified nursing assistant, identified as CNA-G, had just delivered R3's dinner tray and stepped out to pass trays to other residents. Moments later, CNA-G heard R3 yelling from the room. R3 was on the floor.
The missing piece was a Dycem, a thin non-slip mat placed on a wheelchair seat to prevent a resident from sliding forward and falling out. R3 had an active fall intervention in their care plan requiring the Dycem to be on the wheelchair at all times. The cushion was there. The Dycem was not.
CNA-G told the surveyor that wheelchair equipment is supposed to be checked at the start of each shift. The surveyor asked directly what CNA-G believed caused the fall. CNA-G said it was the missing Dycem.
CNA-G also described R3 as someone who "can be difficult" — a resident who puts things in the wheelchair, messes up the room, and can become very confused. That description didn't explain why the Dycem was absent. It described the resident.
The inspection was a complaint survey, conducted September 3. That same afternoon, at 2:28 p.m., the surveyor sat down with the facility's nursing home administrator and laid out the concern plainly: R3 has a history of falls, carries a high fall risk, has an active intervention requiring the Dycem, and fell on August 30 when the Dycem wasn't there. The administrator acknowledged the concern. Nothing further was provided.
The violation was cited under F0689, which covers the obligation to keep residents free from accidents the facility could reasonably prevent. CMS rated the harm level as minimal or potential, with few residents affected.
What the inspection record shows is narrow but clear. A resident who falls, who was known to fall, who had a specific plan in place to prevent falling, fell. The plan called for a mat. The mat wasn't there. The staff member who left the room knew what the intervention was and knew it was supposed to be checked.
The administrator's acknowledgment closed the interview. No corrective steps, no explanation of how the Dycem came to be missing that evening, no account of whether this had happened before, appeared anywhere in the report. The record ends where the conversation did.
R3 was on the floor. The Dycem was somewhere else.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina of Kenosha from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Avina of Kenosha in Kenosha, WI was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records only as R3, fell on August 30 at Avina of Kenosha.
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.