Avina Of Weyauwega

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

provided Resident R7 with illegal drugs and alcohol. (GD-F did not indicate when the information was reported to FNHA-E.) GD-F indicated the facility did not monitor Resident R7 to make sure Resident R7 did not receive illegal drugs and THC was discovered in Resident R7's urine. GD-F indicated GD-F informed FNHA-E that Resident R7 could not be exposed to alcohol, CBD/THC, or any illegal drugs due to Resident R7's history of Wernicke's encephalopathy. GD-F also stated GD-F found a gummy (THC) wrapper in Resident R7's pants that were brought home to be washed. During an emergency room (ER) visit, Resident R7's urine drug screen (collected on 7/5/25) was positive for THC. GD-F also indicated a vape was found in Resident R7's room which was given to FNHA-E and later given back to Resident R7. GD-F was unsure if the vape contained THC or tobacco and did not know what steps the facility took to ensure Resident R7 was not exposed to illegal drugs or alcohol. Surveyor reviewed the results of Resident R7's urine drug screen (collected on 7/5/25) which were presumptive positive for cannabinoids.On 8/27/25 at 11:45 AM, Surveyor interviewed Regional Director of Operations (RDO)-C in the presence of Assistant Director of Nursing (ADON)-B and NHA-A. RDO-C, ADON-B, and NHA-A were not aware of GD-F's concerns, including Resident R7's presumptive positive urine drug screen for cannabinoids, since they were not at the facility when the concerns were reported. RDO-C verified FNHA-E did not file a grievance but wrote a note (on 7/7/25) that indicated FNHA-E had a discussion with GD-F. It was uncertain what FNHA-E did after becoming aware of

the presumptive positive THC test. A follow-up visit with Resident R7's provider occurred on 7/9/25 but there was no mention of the test. RDO-C was unsure if the presumptive positive was due to the medications that Resident R7 took and was uncertain what nursing staff did after becoming aware of the results of the test. No evidence of illegal drugs was found for Resident R7.On 8/27/25 at 12:35 PM, Surveyor interviewed Social Services Director (SSD)-G who indicated FNHA-E informed SSD-G that GD-F stated Resident R7 should not be exposed to illegal drugs or alcohol. SSD-G indicated FNHA-E stated FNHA-E would take care of the situation.On 8/27/25 at 3:05 PM, Surveyor interviewed RDO-C who verified FNHA-E should have filed a grievance for GD-F's concerns.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avina of Weyauwega

717 E Alfred St Weyauwega, WI 54983

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

indicate to notify the Nursing Home Administrator (NHA) if observed so law enforcement could be contacted per the facility's policy. Surveyor noted the care plan was not updated after Resident R6's presumptive positive urine drug screen on 5/27/25. 2. From 8/25/25 to 8/27/25, Surveyor reviewed Resident R7's medical record. Resident R7 was admitted to the facility on [DATE REDACTED] and had diagnoses including dementia, Wernicke's encephalopathy (a brain disorder caused by vitamin B1 deficiency commonly associated with chronic alcohol abuse), alcohol dependence, fatty liver, and depression. Resident R7's MDS assessment, dated 8/13/25, had

a BIMS score of 11 out of 15 which indicated Resident R7 had moderately impaired cognition. Resident R7 had a Guardian who was responsible for Resident R7's healthcare decisions.Resident R7's medical record contained a urine drug screen panel, collected on 7/5/25, that was presumptive positive for THC.Resident R7's care plan, dated 4/1/25, indicated Resident 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 Resident R7 to express thoughts or feeling, encourage Resident R7 to follow MD orders, monitor for signs that Resident R7 was drinking, instruct Resident R7 that drinking is against facility policy and may lead to involuntary discharge, monitor Resident 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 Resident 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 Resident R6 and Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avina of Weyauwega

717 E Alfred St Weyauwega, WI 54983

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

community and was at minimal risk for aggression. There were no other similar assessments completed

during Resident R2's stay at the facility.Resident R2's hospital History and Physical (H&P) (received and scanned into Resident R2's medical record on 6/23/25) indicated Resident R2 had a diagnosis of paranoid schizophrenia. Surveyor noted Resident R2's facility diagnoses list, care plan, and Aggressive and Harmful Behavior Assessment did not include the diagnosis. Resident R2's hospital H&P and referral documentation also indicated Resident R2 received 1:1 supervision in the hospital due to ongoing suicidal and homicidal ideation. On 8/26/25, Surveyor reviewed Resident R2's psychotherapy progress notes which included a diagnosis of paranoid schizophrenia that was indicated prior to Resident R2's admission to the facility on 6/23/25. Surveyor noted Resident R2's psychiatric provider completed a suicidal ideation/homicidal ideation (SI/HI) safety plan, dated 5/11/25, that was not included in Resident R2's medical record.

Surveyor reviewed Resident R2's facility progress notes and noted the following: ~ On 6/30/25. Resident R2 was seen by Nurse Practitioner (NP)-D who indicated Resident 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. Resident R2's medical record did not indicate Resident R2's outside psychiatric provider was updated to obtain orders or recommendations.~ Resident R2 was hospitalized from [DATE REDACTED] to 7/11/25 due to medical concerns.

Hospital discharge documentation, dated 7/11/25, indicated a referral for a neuropsych evaluation was completed. Resident R2's medical record did not indicate a neuropsych appointment was made.~ On 7/16/25, Resident R2 was seen by NP-D who documented Resident R2 had underlying diagnoses of paranoid schizophrenia, PTSD, and psychogenic syncope. The note indicated NP-D would ensure Resident R2 had psychiatric follow-up and contained a recommendation to contact Hospital (HSP)-H for a neuropsych evaluation.~ On 8/6/25, Resident R2 was seen by NP-D who indicated Resident R2's psychiatric status remained a significant concern. Following an incident on 8/3/25 when Resident R2 hit Resident R2's head against the wall and reopened a forehead abrasion, there were ongoing concerns.

Nursing staff reported that Resident R2 attempted to self-harm again on 8/5/25 but was redirected. The note indicated nursing staff would contact Resident R2's outside psychiatric provider again for a plan of care. Resident 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 Resident 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 Resident R2. ADON-B indicated paperwork with Resident R2's paranoid schizophrenia diagnosis was received, however,

the facility did not communicate or care plan the diagnosis correctly to ensure Resident R2 received the appropriate care and treatment. ADON-B verified consistent communication occurred with Resident R2's outside psychiatric provider and indicated calls were made for updates. ADON-B was unsure if Resident 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 Resident 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 Resident R2's neuropsych evaluation was not scheduled and did not occur.

Event ID:

Facility ID:

If continuation sheet