Avina Of Weyauwega

including dementia, Wernicke's encephalopathy (a brain disorder caused by vitamin B1 deficiency

moderately impaired cognition. R7 had a Guardian who was responsible for R7's healthcare

presumptive positive for THC.R7's care plan, dated 4/1/25, indicated R7 had a history of substance abuse/chemical dependency related to a history of alcohol abuse.

The care plan contained interventions (dated 4/7/25) to encourage R7 to express thoughts or feeling, encourage R7 to follow MD orders, monitor for signs that R7 was drinking, instruct R7 that drinking is against facility policy and may lead to involuntary discharge, monitor R7 for behaviors, and notify the MD and Social Services of any changes.

The care plan did not include monitoring for the presence of illegal drug use and did not indicate to notify the NHA if observed so law enforcement could be contacted per the facility's policy.

Surveyor noted the care plan was not updated after R7's presumptive positive urine drug screen on 7/5/25.On 8/27/25 at 3:05 PM, Surveyor interviewed Regional Director of Operations (RDO)-C who verified R6 and R7's care plans should have been updated to include monitoring for the presence of illegal drug use and to notify the NHA if observed so law enforcement could be notified per the facility's policy.

525315 08/27/2025

Avina of Weyauwega 717 E Alfred St Weyauwega, WI 54983

Harmful Behavior Assessment did not include the diagnosis. R2's hospital H&P and referral

included a diagnosis of paranoid schizophrenia that was indicated prior to R2's admission to the

ideation (SI/HI) safety plan, dated 5/11/25, that was not included in R2's medical record.

Surveyor reviewed R2's facility progress notes and noted the following: ~ On 6/30/25. R2 was seen by Nurse Practitioner (NP)-D who indicated R2 reported sleep difficulties due to waking up with flashbacks, episodes of tearfulness, and hearing voices.

The note indicated nursing staff would reach out regarding the concerns. R2's medical record did not indicate R2's outside psychiatric provider was updated to obtain orders or recommendations.~ R2 was hospitalized from [DATE] to 7/11/25 due to medical concerns.

Hospital discharge documentation, dated 7/11/25, indicated a referral for a neuropsych evaluation was completed. R2's medical record did not indicate a neuropsych appointment was made.~ On 7/16/25, R2 was seen by NP-D who documented R2 had underlying diagnoses of paranoid schizophrenia, PTSD, and psychogenic syncope.

The note indicated NP-D would ensure R2 had psychiatric follow-up and contained a recommendation to contact Hospital (HSP)-H for a neuropsych evaluation.~ On 8/6/25, R2 was seen by NP-D who indicated R2's psychiatric status remained a significant concern.

Following an incident on 8/3/25 when R2 hit R2's head against the wall and reopened a forehead abrasion, there were ongoing concerns.

Nursing staff reported that R2 attempted to self-harm again on 8/5/25 but was redirected.

The note indicated nursing staff would contact R2's outside psychiatric provider again for a plan of care. R2's medical record did not contain a progress note, new orders, or a psychotherapy update. ~ On 8/26/25 at 10:00 AM, Surveyor interviewed Regional Director of Operation (RDO)-C and Assistant Director of Nursing (ADON)-B.

ADON-B indicated the admission and MDS nurse missed R2's schizophrenia diagnosis upon admission.

RDO-C indicated if the diagnosis was recognized, it would have been properly assessed and care planned. RDO-C confirmed care plan updates and assessments were not completed following behavioral concerns for R2. ADON-B indicated paperwork with R2's paranoid schizophrenia diagnosis was received, however, the facility did not communicate or care plan the diagnosis correctly to ensure R2 received the appropriate care and treatment. ADON-B verified consistent communication occurred with R2's outside psychiatric provider and indicated calls were made for updates. ADON-B was unsure if R2's care plan/safety plan was requested from the psychiatric provider and was unsure if the psychiatric provider was contacted for collaboration of care since contact attempts were not documented. RDO-C and ADON-B indicated R2's outside psychiatric provider needed to pre-approve the neuropsych evaluation at HSP-H for payment to occur. ADON-B indicated multiple calls were made to follow-up on the evaluation approval, however, return calls were not received. ADON-B confirmed staff did not document any attempts to schedule the neuropsych evaluation. In addition, RDO-C and ADON-B confirmed R2's neuropsych evaluation was not scheduled and did not occur.