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Avina of Weyauwega: Mental Health Care Failures - WI
The diagnosis didn't appear on the facility's diagnosis list....
Latest reports, citations, and penalties from CMS data
The diagnosis didn't appear on the facility's diagnosis list....
When the inspector pointed to it, the dietary manager agreed it was dirty and removed it immediately....
The inspection, conducted August 21, 2025, was triggered by a complaint....
The inspectors who found it described the consistency as resembling salad dressing....
The facility opened an investigation....
The warning did not produce a system to monitor whether R7 was actually receiving those substances....
The inspection, completed August 27, 2025, found that nurses had administered oral medications to residents with NPO status, meaning nothing by mouth....
The resident, identified in inspection records only as R5, was found by a nurse in a prone position on the floor with an injury to the left side of his head....
Nobody stopped it until a third resident walked into the room and started shouting....
Whether it was small in consequence is harder to say....
That nurse, identified in inspection records as RN #300, was the facility's sole MDS nurse....
The assault happened on August 18, 2025, at approximately 2:30 in the afternoon....
The whole process took about two and a half hours....
The facility's own account manager was standing there during the inspection....
The facility discharged the resident, identified in inspection records only as R1, for nonpayment of services....
The incident happened on August 16, 2025....
That last part is worth sitting with....
The gaps ran across multiple shifts and multiple residents throughout the month....
Diclofenac is a prescription-strength anti-inflammatory pain reliever....
Thirty-two residents ate lunch that day with only tea on their trays....