MAYVILLE, WI - Federal health inspectors identified seven deficiencies at Avina of Mayville during a standard health inspection completed on December 4, 2025, including a citation for failing to provide adequate pharmaceutical services to residents. The facility has not submitted a plan of correction for the pharmacy-related violation.
Pharmaceutical Services Found Lacking
The inspection documented a deficiency under federal regulatory tag F0755, which requires nursing homes to provide pharmaceutical services that meet the needs of each resident and to employ or obtain the services of a licensed pharmacist.
Pharmaceutical services in a skilled nursing facility encompass far more than simply distributing medications. Under federal regulations, facilities must ensure that a licensed pharmacist oversees the full spectrum of medication management — from procurement and storage to administration and monitoring. The citation indicates that Avina of Mayville fell short of meeting these requirements.
The deficiency was classified at Scope/Severity Level D, meaning inspectors determined the issue was isolated in scope and did not result in documented actual harm. However, the classification also noted potential for more than minimal harm to residents, indicating the problem could lead to adverse outcomes if left unaddressed.
Why Pharmacy Oversight Matters in Nursing Homes
Nursing home residents are among the most medically vulnerable populations in the healthcare system. The average long-term care resident takes between seven and nine medications daily, and many residents manage complex drug regimens that include blood thinners, insulin, cardiac medications, and psychotropic drugs.
Without proper pharmaceutical oversight, the risk of drug interactions, incorrect dosing, and adverse reactions increases significantly. A licensed pharmacist is responsible for conducting regular medication regimen reviews, identifying potential drug interactions, flagging unnecessary medications, and ensuring that each resident's prescriptions align with their current diagnoses and treatment goals.
Federal regulations under 42 CFR § 483.45 establish clear expectations for pharmacy services in Medicare and Medicaid-certified facilities. These include monthly drug regimen reviews by a licensed pharmacist, proper medication storage and handling procedures, and timely identification of medication-related irregularities.
When these safeguards break down — even in isolated instances — residents face elevated risk of preventable medication errors, which are a leading cause of adverse events in long-term care settings.
No Correction Plan Filed
Perhaps the most notable aspect of this citation is the facility's response — or lack thereof. As of the inspection record, Avina of Mayville's deficiency status is listed as "Deficient, Provider has no plan of correction."
When a nursing home receives a deficiency citation, federal regulations typically require the facility to submit a plan of correction outlining specific steps it will take to address the identified problem, prevent recurrence, and establish a timeline for compliance. The absence of a submitted correction plan raises questions about the facility's approach to resolving the identified gap in pharmaceutical services.
Facilities that fail to submit adequate plans of correction may face escalating enforcement actions from the Centers for Medicare & Medicaid Services (CMS), including directed plans of correction, civil monetary penalties, or — in persistent cases — denial of payment for new admissions.
Broader Inspection Results
The pharmacy services deficiency was one of seven citations issued during the December 2025 inspection. While the full scope of all deficiencies provides a more complete picture of the facility's compliance status, the pharmacy citation on its own highlights an area of care that directly affects medication safety for every resident.
Families and advocates can review the complete inspection results, including all seven deficiency citations, through the CMS Care Compare database or by requesting records directly from the facility.
What Residents and Families Should Know
Residents of skilled nursing facilities have the right to receive care that meets professional standards, including proper medication management overseen by a licensed pharmacist. Family members who have concerns about a loved one's medication management can contact the Wisconsin Long-Term Care Ombudsman Program or file a complaint with the Wisconsin Department of Health Services.
The full inspection report for Avina of Mayville provides additional details on all cited deficiencies and is available for public review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina of Mayville from 2025-12-04 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.