Skip to main content
Complaint Investigation

Avina Of Mayville

February 21, 2025 · Mayville, WI · 305 S. Clark St.
Citations 1
CMS Rating 3/5
Beds 80
Provider ID 525616
Healthcare Facility
Avina Of Mayville
Mayville, WI  ·  View full profile →
Inspection Summary

Avina of Mayville in Mayville, WI — inspection on February 21, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF609
Minimal harm or centered care affected

The facility failed to create a care plan related to R2's alcohol consumption and failed to implement interventions for behaviors associated with R2's alcohol consumption.

This is evidenced by:

The facility policy titled Safety for Resident with Substance Use Disorder, dated 1/25, states in part: It is the policy of this facility to create an environment that is as free of accident hazards as possible, for residents with a history of substance use disorder.

Definitions: substance use disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home . 1.

Residents with a history of SUD will be assessed for risks .

Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2.

When substance use is suspected .facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3.

Care planning interventions will address risks by providing appropriate diversions for resident and encouraging resident to seek out facility staff to discuss their plan of care .7.

The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with their resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision.

R2 admitted to the facility on [DATE] with diagnoses including alcohol abuse, repeated falls, unsteadiness on feet.

R2's Brief Interview for Mental Status (BIMS) on 11/26/24 has a score of 15, indicating R2 is cognitively intact.

R2's Medication administration and Treatment administration records for January 2025 and February 2025 do not include monitoring of behaviors and/or substance use.

R2's physician orders dated 2/21/25 does not include an order stating R2 can consume alcoholic beverages.

R2's comprehensive care plan dated 2/21/25, states in part:

Focus: The resident is functioning at an independent level in his leisure pursuits.

Goal: The resident will make one positive statement about his leisure pursuits to staff weekly.

525616

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525616 B.

Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crossroads Care Center of Mayville 305 S Clark St Mayville, WI 53050

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Mayville, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avina of Mayville or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement