Avina of Weyauwega: Schizophrenia Diagnosis Missed - WI
The admission nurse missed the schizophrenia diagnosis entirely. The Assistant Director of Nursing confirmed it to an inspector on August 26: the paperwork was there, the diagnosis was in it, and nobody caught it.
By late June, a nurse practitioner was already documenting that the resident was waking up with flashbacks, crying, and hearing voices. The note said nursing staff would follow up with concerns. The outside psychiatric provider was never contacted for orders.
The resident was hospitalized in early July. Discharge paperwork recommended a neuropsychological evaluation. No appointment was made.
On August 3, the resident hit their head against a wall hard enough to reopen a forehead abrasion. Two days later, staff redirected another self-harm attempt. The nurse practitioner's August 6 note called the resident's psychiatric status "a significant concern" and said staff would contact the outside provider again for a plan of care. No progress note, no new orders, and no psychotherapy update followed.
The neuropsych evaluation was never scheduled. The Regional Director of Operations told the inspector that the outside psychiatric provider needed to pre-approve the evaluation for payment. The ADON said staff made multiple calls chasing that approval and got no callbacks. She also confirmed that none of those calls were documented, that she wasn't sure whether anyone had ever requested the resident's safety plan from the psychiatric provider, and that she couldn't say whether the provider had been contacted for actual care collaboration at all.
A suicidal ideation and homicidal ideation safety plan, completed by the resident's psychiatric provider on May 11, before admission, was never placed in the resident's medical record at the facility.
The Regional Director of Operations put it plainly: if the diagnosis had been recognized on admission, it would have been properly assessed and care planned. It wasn't recognized. It wasn't assessed. It wasn't care planned. And a resident with a known history of self-harm spent two months in a facility that, on paper, didn't know why.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
Avina of Weyauwega in Weyauwega, WI was cited for violations during a health inspection on August 27, 2025.
The admission nurse missed the schizophrenia diagnosis entirely.
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.