Avina of Weyauwega

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 23, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 1, 2025

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 22, 2025

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 22, 2025

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 22, 2025

Give the resident's representative the ability to exercise the resident's rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2025

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2025

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2025

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected August 12, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2025

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 12, 2024

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2025

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2025

Give the resident's representative the ability to exercise the resident's rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 6, 2023

Perform COVID19 testing on residents and staff.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 6, 2023

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2023

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2023