Avina On Division

pretty independent. LPN1 stated that if staff were not responsive, R2 would call on the facility's

short of breath. LPN1 stated she was completing the medication pass when R2 told her she may need

could see R2 was not in dire need and by the time she went down to the resident's room, which was in maybe five minutes, the resident's husband had already called 911. LPN1 stated R2 had just came back in from smoking and stated her chest had been feeling funny lately. LPN1 stated R2 will say things like that a lot and nothing seemed different.

When asked what the resident specifically said to her, the LPN stated that all the resident said was, I may need to go out. LPN1 stated that because R2 complained about different things and ailments and was talking fine and was not short of breath, she figured she had a few minutes to get down there (to the resident's room.) LPN1 was asked if she would have responded differently if this had been any other resident. LPN1 stated she would have assessed them. LPN1 was asked if anything had happened as a result of this incident.

She stated that the Administrator and DON talked to her about it. LPN1 stated she had been instructed that an assessment should have been completed.

During an interview on 03/28/26 at 4:39 PM, the Medical Director stated it was her expectation that when a resident stated they wanted to go to the hospital, staff would conduct an assessment, obtain vital signs, and report to her or the Nurse Practitioner.

The Medical Director stated this was the first time she had heard about the incident with R2 but that the Nurse Practitioner might be aware.

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Avina on Division 517 E Division St Fond Du Lac, WI 54935

During an interview on 03/26/26 at 4:20 PM, the ADON stated LPN1 was not certified to be able to administer medications via IV/peripherally inserted central catheter (PICC) lines.

During an interview on 03/27/26 at 3:14 PM, LPN1 stated she had been hanging IV medications to be administered via PICC lines since she was employed at the facility. LPN1 stated she had not received any type of formal training from the facility on administering IV medications, however, this was something she had learned while in school to become an LPN.

Continued interview revealed at times she was the only nurse in the facility to be able to administer medications to residents with PICC lines; the other staff person was a CMA/MT.

During an interview on 03/28/26 at 7:16 PM, the FDON stated during her employment at the facility she was responsible for the oversight and supervision of licensed nursing staff.

When asked if LPN1 and LPN2 had received additional training/certification to be able to administer medications intravenously, the FDON stated she had observed both LPNs administer IV medications and had no concerns.

Example 5:R6 admitted to the facility on [DATE] with diagnoses to include sepsis, diabetes type 2, congestive heart failure, and end stage renal disease (ESRD).R6's NRSG (nursing): admission Data Collection Progress Notes, dated 03/24/26 was completed by LPN4.R6's Nurses Note, dated 03/24/26 was completed by LPN1 and included details of R6's admission to the facility.There was no evidence that an RN completed R6's assessment.Example 6:R8 admitted to the facility on [DATE] with diagnoses to include chronic congestive heart failure.R8's NRSG: admission Data Collection Progress Notes, dated 03/17/26 was completed by LPN4.R8's NRSG: admission Data Collection and Baseline Care Plan Tool-V 11, dated 03/17/26 was completed and signed by LPN4.There was no evidence that an RN completed R8's assessment.Example 7: R9 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD) and traumatic ischemia of muscle.R9's NRSG (Nursing): admission Data Collection Progress Notes, dated 03/17/26 was completed by LPN1.R9's NRSG: admission Data Collection and Baseline Care Plan Tool-V 11, dated 03/17/26 was completed and signed by LPN1.There was no evidence that an RN completed R9's assessment.

During an interview on 03/28/26 at 7:16 PM, the FDON stated during her employment at the facility she was responsible for the oversight and supervision of licensed nursing staff.

When asked who should be completing admission assessments on newly or readmitted residents, the FDON stated LPNs complete a lot of them because 99% of admissions are on the evening shift. FDON stated she would always review admission assessments completed by LPNs on her next scheduled day of work.

When asked per an LPN's scope of practice, were LPNs permitted to complete residents' admission assessments, the FDON stated probably not, but she was the only RN employed by the facility.

During an interview on 03/26/26 at 4:20 PM, ADON stated since the facility has been without a DON who was the facility's only employed Registered Nurse (RN,) LPNs have been completing all initial nursing assessments for newly admitted residents.

During an interview on 03/27/26 at 3:14 PM, LPN1 stated she completes residents' admission assessments when they are admitted to the facility.

During an interview on 03/28/26 at 8:12 PM, LPN6 stated they (LPNs) started doing all of residents' admission assessments approximately seven or eight years ago.

During an interview on 03/28/26 at 8:20 PM, LPN5 stated prior to her being educated this date, LPNs could complete residents' admission assessments.

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Avina on Division 517 E Division St Fond Du Lac, WI 54935

stated CMAs were only allowed to give PRN pain medication after a nurse had completed an

jeopardy to resident health or the pain assessments on residents.

When asked who should be completing admission assessments on safety newly or readmitted residents, the FDON stated that LPNs complete a lot of them because 99% of admissions are on the evening shift.

The FDON stated she would always review admission

Registered Nurse ensuring the minimum requirement of having an RN providing services at least eight consecutive hours a day, seven days a week, the the failure to employ an RN who was designated to serve as the Director of Nursing on a full-time basis created a likelihood for serious harm, thus leading to a finding of immediate jeopardy beginning on 03/14/26.

The facility removed the immediate jeopardy on 03/28/26, however, the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement the following action plan: Employ a full-time interim DONProvide staff education on notification of changes in conditionAssessments of nurses' IV competencyEmployment of an agency RN to ensure RN coverage on Saturdays and SundaysReassess all residents with IVs, pressure injuries, new admissions since 03/14/26Reassess all residents with a documented change in condition since 03/14/26

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Avina on Division 517 E Division St Fond Du Lac, WI 54935

During an interview with LPN1 on 03/27/26 at 3:14 PM, LPN1 was asked about the wrong antibiotic being given to R2. LPN1 stated it was an honest mistake and the facility previously only had one resident with an IV. LPN1 stated on that day, she didn't check thoroughly enough and grabbed the wrong one out of the refrigerator.

When LPN1 was asked what happened after she realized the wrong antibiotic was given to R2, she said the DON had her notify the on-call physician to see if there would be an issue. LPN1 stated she was educated on the five patient rights.

When asked if others were trained, she stated it was just her, adding that it was a stupid mistake and should not have happened.

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Avina on Division 517 E Division St Fond Du Lac, WI 54935

Observation on 03/26/26 at 3:33 PM of the kitchen revealed multiple cobwebs and dead insects on the wall behind the portable shelving where clean dishes were stored, extending from the window to the edge of the window seal, directly behind the shelving.

Continued observation revealed a build up of black and gray dust and debris. To the left of the shelving were two window unit air conditioners which had the potential to blow debris and pests onto clean dishes if the air conditioners were turned on.During observations and an interview on 03/26/26 at 3:38 PM, Dietary Aide (DA) 1 observed the concerns listed above in the walk-in cooler and walk-in freezer. DA1 stated all dietary staff should be checking use-by and expiration dates and removed the items from the cooler and freezer.During an observation and interview on 03/26/26 at 3:45 PM, DA1 observed the wall behind the shelving with clean dishes. DA1 stated with the air conditioners so close to the shelving, the air conditioners could possibly blow debris and bugs onto clean dishes.

The facility's Dietary Manager resigned on 03/23/26; therefore, there was no interview with the Dietary Manager.

During an interview on 03/28/26 at 8:52 PM, the Regional Director of Operations (RDO) stated it was her expectation that the kitchen would not have items beyond the use-by and expiration dates and would not have dust and dead bugs.

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Avina on Division 517 E Division St Fond Du Lac, WI 54935

halls to assist residents if they need help.

During an interview on 03/26/26 at 11:55 AM, Licensed

an interview on 03/28/26 at 8:52 PM, the RDO stated it was her expectation the facility would have