Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avina Of Mayville during CMS and state inspections, most recent first.
Meals Served at Undesirable Temperatures: Multiple residents reported receiving hot foods cold, including breakfast items such as eggs, and resident council members voiced the same concern. Surveyors observed meal service and test trays with hot foods below the facility’s stated temperature standard and a cold drink above the cold-food standard. The DM stated trays were sometimes left in hallway carts or on tables too long before residents were served, and leadership acknowledged residents should receive meals at a safe and desirable temperature.
Surveyors observed unsafe food storage, sanitation, and dish handling practices in the kitchen. Mighty Shakes were stored in the refrigerator without a thaw date, the stove hood had hairlike dust above the cooking area, and the mixer and meat slicer were stored with dried food debris. Staff were also observed drying dishes with a towel, stacking wet cups, and serving food without a beard restraint.
An Activity Assistant and an LPN were observed moving several residents in wheelchairs from behind in the dining room without warning, explanation, or front-facing communication. Residents with varying levels of cognitive impairment, including dementia, PTSD, and stroke-related deficits, appeared startled, confused, or disoriented during the transfers. Facility leadership stated residents should be approached from the front, identified, and told what is happening before being moved.
A resident with alcohol, cocaine, and nicotine dependence was observed charging his motorized wheelchair in his room while seated in it, even though staff stated the chair should not be charged there and the unit had a lithium battery. The same resident also kept multiple 30-packs of beer in his room despite a care plan stating alcohol would be held in a locked area, and records showed another resident had entered his room and taken a beer. Staff reported the resident would not allow the beer to be locked up.
A resident with a chronic Foley catheter and a history of recurrent complicated E. coli UTIs had the catheter drainage bag, including the spout, observed in direct contact with the floor. The ANHA, RN/IP, DON, and NHA stated the bag should not touch the floor and should have a dignity cover, but the resident was observed without one while in the dining room.
A resident with ESRD, type 1 DM, and dialysis dependence did not receive ordered Nephrocaps as prescribed. The MAR showed repeated medication omissions, nurses’ notes only documented that the medication was unavailable and pharmacy would deliver it, and there was no further follow-up documentation when it remained unavailable. The resident said he was waiting on his vitamin after dialysis, and both an LPN and the DON stated that a nurses’ note should accompany the MAR notation.
Infection control breaches occurred during wound care, INR testing, and insulin administration. An APNP removed wound dressings and handled supplies without proper hand hygiene between steps, an RN carried an INR machine with a used test strip out of the room before disinfecting it, and an LPN placed a clean supply kit on bed linens, mixed a used insulin pen with clean supplies, and removed a used needle from the pen with bare hands. Facility staff acknowledged the expected infection control practices during interview.
A resident with a history of acute kidney failure and other conditions did not receive the final dose of a prescribed antibiotic because the pharmacy delivered an insufficient quantity. The missing dose was not administered when it arrived late, and the LPN did not notify the provider or leave notes for other nurses. The DON confirmed there was no documentation of the missed dose being reported, contrary to facility policy.
The facility failed to report a resident-to-resident altercation involving verbal abuse, as required by policy. Despite being aware of the incident, the NHA did not report it to the state agency, citing a flowchart that suggested it was not willful. However, the facility did not document an immediate assessment or lack of willful intent. The incident involved two residents, one cognitively intact and the other with moderate cognitive impairment, and occurred in their shared room.
A resident with dementia and anxiety exhibited aggressive behaviors, but the facility failed to include specific triggers and interventions in the care plan. Staff were aware of the behaviors but relied on informal interventions not documented in the care plan or CNA Kardex, leading to a deficiency in providing person-centered care.
A facility failed to provide necessary behavioral health services for a resident with a substance use disorder (SUD), specifically related to alcohol consumption. Despite the resident's cognitive intactness and diagnoses of alcohol abuse and repeated falls, the facility did not create a comprehensive care plan addressing the SUD or implement interventions for associated behaviors. The care plan focused on leisure pursuits without addressing substance use, its triggers, or associated behaviors. Staff interviews confirmed the absence of a care plan for the resident's substance use, and the director of nursing acknowledged this oversight.
A resident with cognitive deficits was observed with a medication unsupervised, without a completed assessment or physician order for self-administration. The facility's policy requires such an assessment and order, which were not in place. The resident expressed confusion about the medication, and staff confirmed the lack of necessary documentation and supervision.
A resident with anxiety and depression did not have a comprehensive, person-centered care plan that included non-pharmacological interventions, despite having active orders for anti-anxiety and anti-depressant medications. The facility's policies require such interventions, but the care plan lacked them, as confirmed by the DON during a surveyor interview.
A resident with a history of traumatic brain injury experienced two unwitnessed falls, but the facility failed to consistently complete required neurological assessments. On one occasion, the nurse was on the phone with the resident's family, and on another, the nurse did not want to wake the resident. Additionally, the facility did not document a comprehensive clinical assessment or obtain a physician's order before transferring the resident to the hospital at the family's request.
A resident with a history of TBI experienced multiple falls due to the facility's failure to conduct thorough investigations and update the care plan with effective fall prevention strategies. Despite being assessed as a fall risk, the resident's care plan was not adequately revised following each incident, and the facility did not perform comprehensive assessments to determine causative factors. The lack of documentation and communication of fall risk interventions contributed to the repeated falls.
A resident did not receive propranolol as prescribed for tremors due to a transcription error upon admission. The medication was incorrectly ordered for hypertension and administered once daily instead of twice. The error was discovered after the resident was transferred out of the facility.
The facility did not provide two residents with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) forms when their Medicare Part A benefits ended. This form is crucial for informing residents about changes in coverage, financial liability, and appeal rights. Instead, only the Notice of Medicare Non-Coverage (NOMNC) forms were given, which do not meet the same requirements. The Nursing Home Administrator confirmed that the previous social worker failed to issue the SNFABN forms, resulting in the deficiency.
A resident, who is cognitively intact and dependent on staff for toileting, expressed a preference for privacy by having window curtains closed during personal care. Despite this, staff members, including a CNA, RN, and DON, were observed providing care with the curtains open, allowing visibility from a public patio. The resident consistently communicated the desire for privacy, but staff either did not ask or assumed the resident did not care, leading to a deficiency in maintaining privacy.
A resident returned from a hospital stay with an indwelling catheter, which remained in place for nearly two months without documented medical justification, contrary to the facility's policy requiring a physician's order and medical justification for catheter use. The resident was initially admitted to the hospital with acute respiratory failure and placed on comfort care. The catheter was left in for comfort and hospice care, but was eventually removed after the resident's condition improved.
A facility failed to provide proper dialysis care for a resident with ESRD, lacking physician's orders for dialysis and monitoring of the AV fistula site. The care plan did not address the type of dialysis or the presence of the AV fistula, and staff did not consistently document assessments of the fistula. Interviews revealed a lack of understanding among staff about the necessary orders and documentation, leading to a deficiency in care.
Meals Served at Undesirable Temperatures
Penalty
Summary
The facility did not ensure that residents received food and drink that were palatable and at a safe and appetizing temperature. Multiple residents and resident representatives reported that hot meals were being served cold, including breakfast items such as eggs and other hot foods. During the resident council task meeting, several residents stated their hot meals were often served at a cold and undesirable temperature, and one resident representative reported that a resident’s hot meal was served cold at times and that food sat on the table before the resident arrived in the dining room. Surveyors observed meal service and completed test tray observations that showed food temperatures below the facility’s stated standards. One test tray included roast beef at 126.7 degrees F, peas at 133.3 degrees F, scalloped potatoes at 141.4 degrees F, and a grape drink at 44.8 degrees F. The Dietary Manager stated hot food should be held at 135 degrees F or higher and cold food at 41 degrees F or lower. Another observed tray for a resident who was not present when the tray was first placed on the table later had roast beef at 102.9 degrees F, potatoes at 109.6 degrees F, and milk at 58.1 degrees F, which the Dietary Manager said was not palatable. Record review and interviews showed the issue affected residents with varying cognitive status, including residents with intact cognition and others with impaired cognition. Several residents stated they rarely or never received hot meals, and one resident said breakfast was cold again. The Dietary Manager stated dietary staff plated the food and set up the trays, but nursing staff served the residents, and that trays were sometimes left sitting in hallway carts and at tables for long periods, causing temperatures to drop before residents received them. The DON, NHA, and ANHA stated residents should be served meals at a safe and desirable temperature and that trays should not be set at tables until residents were ready to eat.
Unsafe Food Storage, Equipment Sanitation, and Dish Handling Practices
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation, storage, distribution, and service. During observation of the kitchen, surveyors found 2 boxes of Mighty Shakes in the walk-in refrigerator without a thaw date, and the Dietary Manager was unsure how long the product remained good after thawing until the manufacturer’s instructions were reviewed. The stove hood above the food cooking area had hairlike dust on the front inside panel, and the Dietary Manager stated the dust could dislodge into open food. The mixer and meat slicer were also observed stored under plastic coverings with dried food debris on them, despite staff indicating the equipment should be cleaned before storage. Surveyors also observed unsafe dishwashing and food service practices. A staff member washed dishes in the three-compartment sink and then dried three items with a towel instead of allowing them to air dry, and another staff member was observed stacking wet cups, with water and a white film visible inside the cups when unstacked. In addition, a staff member serving food was observed without a beard restraint, and the Dietary Manager stated the facility had used beard restraints previously but could not find them at the time of the observation.
Residents Moved From Behind Without Warning or Explanation
Penalty
Summary
The facility did not ensure that residents were treated with dignity and respect during wheelchair transport and repositioning in the dining room. During observation of the lunch meal service, surveyors saw an Activity Assistant and an LPN approach residents from behind and move them to different tables without warning, without facing them from the front, and without explaining what was happening. Residents were moved while seated in wheelchairs, and the observed actions were described as not respectful by facility leadership during interview. For R28, who was admitted with diagnoses including COPD, type 2 diabetes, CHF, and cognitive communication deficit, the most recent MDS showed a BIMS score of 12, indicating moderately impaired cognition. Surveyors observed the Activity Assistant pull R28's wheelchair backwards about 10 feet from behind without warning. R28 appeared startled, confused, and disoriented and was gripping the wheelchair handles while being moved. The Activity Assistant later stated she should not have done those things and said she would approach residents from the front and explain what she was doing. Similar observations were made for R16, R25, R26, R49, and R62. R16 had diagnoses including PTSD, anxiety disorder, unspecified mood affective disorder, and cognitive communication deficit, with a BIMS score of 9. R26 had diagnoses including hemiplegia and hemiparesis following stroke, major depressive disorder, vascular dementia, and anxiety disorder, with staff assessment indicating memory problems and severely impaired cognitive skills. R49 had Alzheimer's disease with late onset, dementia, osteoarthritis, and muscle weakness, with a BIMS score of 4. R25 had chronic kidney disease, major depressive disorder, unspecified dementia, and Alzheimer's disease, with a BIMS score of 4. R62 had unspecified dementia, major depressive disorder, cognitive communication deficit, and adjustment disorder with anxiety, with a BIMS score of 1. In each case, staff approached from behind and moved the resident without warning or explanation, and the residents were observed looking startled, confused, or disoriented. Facility leadership stated residents should be approached from the front, staff should identify themselves, explain what is happening, and ask if it is okay before doing something, and that pulling someone from behind or approaching from behind is not respectful.
Unsafe Charging of Motorized Wheelchair and Unsecured Alcohol in Resident Room
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for a resident with diagnoses including alcohol use, alcohol dependence, cocaine use, and nicotine dependence. Survey staff observed the resident sitting in his motorized wheelchair in his room while the chair was plugged into an electrical outlet and charging; the wheelchair contained a lithium battery. A CNA stated the chair should not be charging in the resident’s room, and an LPN stated she was not sure where the chairs were supposed to be charged. The DON and NHA later stated motorized wheelchairs should not be charging in residents’ rooms with residents present. The facility also did not adequately control access to the resident’s alcohol in his room. The resident’s care plan stated he could have beer and cigarettes on the premises and that staff would hold them in a locked area, but nurse notes documented another resident entered his room and took a beer. Survey observations found multiple 30-packs of beer in the resident’s room unattended, including two full 30-packs, another 30-pack with a few cans missing, and later another unopened 30-pack on the floor near his bedside table. The resident stated he drank beer daily, bought it from the gas station, and had experienced another resident entering his room and taking beer. Staff interviews indicated he kept beer in his room because he would not allow staff to lock it up, and the NHA stated the facility had not offered to lock it in his room.
Indwelling Catheter Bag Left in Contact With Floor
Penalty
Summary
The facility did not ensure appropriate care and services were provided for a resident with an indwelling urinary catheter to help prevent a UTI. Surveyors observed the resident’s catheter drainage bag resting in direct contact with the floor, including the spout, during an observation in the dining room. The resident had diagnoses including retention of urine and encounter for attention to other artificial openings of urinary tract, and the record also noted a history of recurrent complicated E. coli UTIs in the setting of a chronic Foley catheter. The facility policy titled Catheter Care, implemented 2/1/25, states that privacy bags will be available and catheter drainage bags will be covered at all times while in use. During the survey, the Assistant Nursing Home Administrator observed the catheter bag in direct contact with the floor and stated it should not be in contact with the floor. The RN/Infection Preventionist later stated the resident had a history of UTIs with sepsis and that the catheter bag or spout should not be in direct contact with the floor. The DON, NHA, and ANHA also stated catheter bags should have dignity covers and should not be in direct contact with the floor.
Missed Nephrocaps Doses and Incomplete Documentation
Penalty
Summary
The facility did not ensure pharmaceutical services were provided to meet each resident’s needs, including accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. This affected 1 of 16 sampled residents, a long-term resident with end stage renal disease, type 1 diabetes mellitus, and dependence on renal dialysis. The resident had a physician order for Nephrocaps 1 mg, 1 capsule by mouth daily as a supplement, but the Medication Administration Record documented the medication with a “10” on multiple dates in November, and the facility policy and procedure for medication administration did not address omitted medications. Nurses’ notes documented that the medication was unavailable and that pharmacy would deliver it on one date, and later again documented the medication was unavailable with a later delivery date. However, there was no further documentation showing follow-up when the medication remained unavailable. During interview, the resident stated he was waiting on the pill he takes after dialysis and said he had not had it for about a week. An LPN stated that a “10” on the MAR means there should be a nurses’ note written about the medication, and the DON stated the resident should receive the Nephrocaps as ordered and that a nurses’ note should absolutely be present when staff document “10” on the MAR.
Infection Control Breaches During Wound Care, INR Testing, and Insulin Administration
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The deficiency involved 1 of 5 residents observed for medication administration, 1 of 1 resident observed for wound care, and 1 of 1 observation of equipment disinfection. The facility’s policies stated that all staff are responsible for following infection prevention procedures, that hand hygiene must be performed according to facility policy, and that reusable items and equipment requiring cleaning or disinfection must be cleaned according to current procedures. During wound care for a resident with wounds to the coccyx and abdominal fold, an APNP removed the coccyx dressing, removed gloves, picked up clean dressing supplies, then set the gloves down and cleansed hands. The APNP removed the abdominal dressing, cleansed the wound, and applied ointment while wearing the same pair of gloves. The APNP later removed gloves and cleansed hands. When asked, the APNP stated hand hygiene is required any time gloves are removed and confirmed it is needed after glove removal and before touching additional supplies. The facility’s wound care policy stated that after removing the existing dressing and gloves, hands are to be washed before putting on clean gloves. During an INR check, an RN carried the INR machine down the hall wearing gloves and set it on multiple surfaces at the nurse’s station with a used test strip still in the machine. The RN stated the machine had been exposed to blood during the test and should have been disinfected and hands cleansed before leaving the resident’s room. During insulin administration, an LPN set a clean supply kit on the resident’s bed linens, placed the used insulin pen into the supply kit with clean supplies, and later handled the used pen with bare hands to remove the needle. The LPN stated the supply kit should not have been placed on the bed, contaminated items should not be placed with clean supplies, and a contaminated needle should not be removed with bare hands.
Missed Antibiotic Dose Due to Medication Unavailability and Communication Failure
Penalty
Summary
The facility failed to ensure that antibiotics were administered as ordered by the physician for a resident with a history of acute kidney failure, malignant neoplasm, and anxiety disorder. The resident was prescribed azithromycin for a sinus infection, with instructions to take two tablets on the first day and one tablet daily for the next four days. Documentation showed that the final dose of azithromycin was not administered because the medication was unavailable. The pharmacy initially delivered only five tablets instead of the required six, resulting in a missed dose. The missing tablet arrived the following night, but by then, the resident had already started a new course of antibiotics. Licensed nursing staff did not notify the physician or nurse practitioner about the missed dose, nor did they leave notes for other nurses regarding the unavailability of the medication. The Director of Nursing confirmed that there was no documentation in the secure communication system indicating that the missed dose was reported to the provider. The resident was aware of the missed dose and reported no ongoing issues at the time of the interview. The facility's policy required staff to notify the pharmacy and the physician when medications were unavailable, but this protocol was not followed in this instance.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an incident of resident-to-resident altercation involving two residents, R5 and R6, as required by their policy on abuse, neglect, and exploitation. The altercation involved R6 verbally abusing R5 by calling them a derogatory name. Despite being aware of the incident, the Nursing Home Administrator (NHA) did not report it to the state agency, citing the facility's Resident-to-Resident Altercation Flowchart, which suggested that the incident did not need to be reported if it was not willful. However, the facility did not document an immediate assessment or a lack of willful intent as required. R5, who is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was reportedly unbothered by the comment. R6, who has a BIMS score of 10 indicating moderate cognitive impairment, has a comprehensive care plan that includes interventions to protect the rights and safety of others due to behavior problems. The incident occurred in the shared room of R5 and R6, and a Certified Nursing Assistant (CNA) witnessed the verbal abuse. The facility's failure to document the incident properly and report it to the appropriate authorities is a violation of their policy and state regulations. The surveyor noted that there was no evidence of an investigation or documentation in the electronic health records regarding the incident, including any assessments, progress notes, or updates to the care plan to prevent recurrence and ensure resident safety.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as R3, who was reviewed for person-centered care plans. R3's care plan did not include specific triggers and monitoring for targeted behaviors, which is a requirement according to the facility's policy on comprehensive care plans. The policy mandates that care plans should include measurable objectives and timeframes to meet the resident's needs, as identified in their comprehensive assessment, and should be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. R3 was admitted with multiple diagnoses, including dementia, anxiety disorder, and major depressive disorder, and required assistance with personal care. Despite these conditions, the care plan lacked specific interventions for R3's aggressive behaviors, which were documented in progress notes. These notes detailed incidents where R3 exhibited aggressive behavior towards staff, such as hitting and kicking, and refusing medications and care. The care plan did not address these behaviors or provide staff with guidance on how to manage them effectively. Interviews with staff, including CNAs and RNs, revealed that while they were aware of R3's behaviors and some informal interventions, these were not documented in the care plan or the CNA Kardex. The Director of Nursing confirmed that behaviors should be listed in the care plan, but they were not. This lack of documentation and formalized interventions in the care plan led to a deficiency in providing quality care tailored to R3's needs.
Failure to Address Substance Use Disorder in Resident Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident with a substance use disorder (SUD), specifically related to alcohol consumption. The resident, who was cognitively intact, was admitted with diagnoses including alcohol abuse and repeated falls. Despite these conditions, the facility did not create a comprehensive care plan addressing the resident's SUD, nor did it implement interventions for behaviors associated with alcohol consumption. The resident's care plan focused on leisure pursuits without addressing substance use, its triggers, or associated behaviors. The facility's policy on safety for residents with SUDs requires comprehensive assessments and care plan interventions, including increased monitoring and supervision. However, the resident's medication and treatment records did not include monitoring for substance use, and there were no physician orders permitting alcohol consumption. The resident's care plan lacked goals and person-centered interventions to prevent substance use or mitigate associated risks. The facility's failure to address these issues was evidenced by multiple incidents of intoxication, falls, and altercations involving the resident. Interviews with facility staff, including a registered nurse and a social services director, confirmed the absence of a care plan for the resident's substance use and associated behaviors. The director of nursing acknowledged that the resident should have had a care plan addressing these issues. The facility's investigation summary noted repeated incidents of alcohol use and related behaviors, including a resident-to-resident altercation where the resident threatened another individual. These findings highlight the facility's failure to adhere to its policy and provide necessary behavioral health services to ensure the resident's highest practicable mental and psychosocial well-being.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed and authorized to self-administer medications. A resident, identified as R3, was observed with a large green pill on their bedside table without staff supervision. The facility did not complete a self-administration of medication assessment for R3, nor was there a physician order permitting R3 to self-administer medications. The facility's policy requires a physician order and an assessment to determine a resident's ability to self-administer medications, which was not adhered to in this case. R3, who was admitted with cognitive communication deficits and other cognitive function issues, was left with medications unsupervised by LPN C. R3 expressed confusion about the medication, indicating uncertainty about its identity and dosage. LPN C admitted to leaving the medications in R3's room without observing their administration and confirmed that R3 did not have the necessary assessment or physician order for self-administration. Both the Nursing Home Administrator and the Director of Nursing acknowledged that R3 experiences confusion and confirmed the absence of the required assessment and order for self-administration.
Failure to Develop Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident (R3) who was reviewed for person-centered care plans. R3 was admitted with diagnoses including anxiety disorder, depression, and cognitive communication deficit. The care plan for R3 included active orders for anti-anxiety and anti-depressant medications but did not incorporate person-centered, non-pharmacological interventions for managing anxiety or depression. This omission was identified during an interview and record review conducted by a surveyor. The facility's policy on Comprehensive Care Plans, dated 9/26/22, emphasizes the importance of developing care plans that incorporate the resident's goals, preferences, and services to maintain their highest practicable well-being. Additionally, the Medication Management policy, dated 10/25/14, outlines the need for ongoing monitoring and the inclusion of non-pharmacological interventions. During an interview, the Director of Nursing (DON B) confirmed that the facility would expect a comprehensive care plan to include non-pharmacologic interventions for residents receiving psychotropic medications, but acknowledged that R3's care plan did not include such interventions.
Failure to Conduct Neurological Assessments and Document Clinical Status
Penalty
Summary
The facility failed to ensure a resident received a neurological assessment after potential head injuries and was comprehensively assessed before being transferred to the hospital. This deficiency was identified in the case of a resident with a history of traumatic brain injury and subarachnoid hemorrhage, who experienced two unwitnessed falls. The facility's policy required neurological assessments after such incidents, but the assessments were inconsistently completed. On one occasion, the nurse did not perform the assessment because they were on the phone with the resident's family, and on another occasion, the nurse did not want to wake the resident due to previous agitation. Additionally, the facility did not document a comprehensive clinical assessment or obtain a physician's order before transferring the resident to the hospital at the family's request. The Director of Nursing stated there was no change in the resident's condition at the time of transfer, but no documentation was provided to support this claim. The lack of proper documentation and adherence to the facility's policy contributed to the deficiency identified by the surveyors.
Failure to Investigate and Prevent Resident Falls
Penalty
Summary
The facility failed to conduct thorough investigations and implement necessary revisions to the care plan following multiple falls experienced by a resident, identified as R104. The resident, who was admitted with a diagnosis of Traumatic Brain Injury (TBI) and assessed as a fall risk, experienced four falls within a short period. Despite the facility's policy requiring comprehensive assessments and root cause analyses for falls, these were not completed for R104's incidents. The initial care plan included interventions such as ensuring proper footwear and using a call light, but these measures were not adequately reassessed or updated following each fall. The first fall occurred in the hallway, where the resident was found with improper footwear and without assistance. The documentation lacked a comprehensive assessment to determine the causative factors, such as what the resident was doing at the time of the fall or when they were last assisted by staff. Subsequent falls in the resident's room and from bed also lacked thorough investigation and documentation of causative factors. The facility did not update the care plan with specific interventions to address the identified risks, such as not leaving the resident alone in their room. The final fall occurred with staff present, where the resident fell while attempting to walk to the bathroom. Again, there was no comprehensive assessment or immediate intervention documented. The facility's failure to conduct root cause analyses and update the care plan with effective fall prevention strategies contributed to the repeated falls. The lack of documentation and communication of fall risk interventions in the resident's Kardex further exemplified the deficiency in providing adequate supervision and a safe environment for the resident.
Medication Transcription Error for Resident
Penalty
Summary
The facility failed to ensure that a resident received a prescribed medication as ordered by the physician. This deficiency was identified during a review of medication administration for a resident who was admitted to the facility from the hospital. The hospital discharge summary indicated that the resident was prescribed propranolol 10 mg to be taken at breakfast and lunch for tremors. However, upon admission to the facility, the medication order was incorrectly transcribed as propranolol 10 mg daily for hypertension, which was not the intended use. As a result, the resident did not receive the medication as prescribed for tremors. The error was discovered during a second check of admission orders by the Assistant Director of Nurses, who believed the corrected order was saved in the computer system. The Medication Occurrence form documented that the medication was clarified to be for tremors and that the nurse practitioner was updated about the error. However, this discovery occurred after the resident had been transferred out of the facility, indicating that the resident did not receive the correct medication order during their stay.
Failure to Provide SNFABN Forms to Residents
Penalty
Summary
The facility failed to provide two residents, R45 and R7, with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) forms when their Medicare Part A benefits were ending. This form is essential as it informs residents about changes in coverage, potential financial liability, and their appeal rights. The surveyor's review revealed that only the Notice of Medicare Non-Coverage (NOMNC) forms were provided to these residents, which do not fulfill the same requirements as the SNFABN. The Nursing Home Administrator acknowledged that the previous social worker, who was responsible for issuing the SNFABN forms, did not provide them to R45 and R7, leading to the deficiency.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of a resident, identified as R7, during personal care activities. R7, who is cognitively intact and dependent on staff for toileting due to frequent incontinence, expressed a preference for the window curtains to be closed during personal care to maintain privacy. Despite this, staff members, including a CNA, RN, and the Director of Nursing, were observed providing personal care to R7 with the window curtains open, allowing visibility from a public patio area. R7 consistently communicated the desire for privacy by having the curtains closed during these activities. The deficiency was observed on multiple occasions, with staff members either not asking R7 about the curtain preference or assuming R7 did not care, despite R7's clear preference for privacy. The facility's failure to respect R7's privacy preference was noted by the surveyor, who confirmed that the room was visible from the public patio when the curtains were open. The Director of Nursing acknowledged the oversight and indicated that R7's preference would be added to the CNA Kardex, but no further information was provided on why the facility did not ensure privacy during personal care.
Lack of Medical Justification for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was medically necessary, as observed in the case of a resident who returned from a hospital stay with an indwelling catheter. The facility's policy requires that catheterization be performed only with a physician's order and medical justification, utilizing proper infection control techniques. However, the resident was readmitted to the facility with a catheter, and there was no documented medical indication for its use. The catheter remained in place for nearly two months without medical justification. The resident, who was admitted to the hospital with acute respiratory failure and later placed on comfort care, returned to the facility with a catheter. Despite the absence of a documented medical diagnosis justifying the catheter, it was ordered to remain in place for gravity drainage. The Director of Nursing later stated that the catheter was left in for comfort and hospice care, but it was eventually removed after the resident's condition improved. The surveyor noted the lack of medical justification for the catheter's use during the exit meeting with facility staff.
Failure to Ensure Proper Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide dialysis care in accordance with professional standards for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who was cognitively intact, had an arteriovenous (AV) fistula in the left forearm for dialysis access. However, the facility did not have physician's orders for dialysis or for monitoring the AV fistula site. The care plan for the resident did not specify the type of dialysis, the presence of the AV fistula, or the necessary monitoring of the fistula site. Observations and interviews revealed that the staff did not consistently assess or document the condition of the resident's AV fistula. A registered nurse claimed to check the fistula daily but could not find any documentation of these assessments in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The Assistant Director of Nursing and the Director of Nursing both acknowledged the need for orders to monitor the fistula site, but no such orders were in place. The deficiency was identified when surveyors noted the lack of documentation and orders, indicating a failure to adhere to the facility's policy on dialysis monitoring and observation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 173 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mayville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hope Health And Rehab | 9 mi | ★★★★★ | 1 | 0 |
| Clearview | 9.2 mi | ★★★★★ | 0 | 0 |
| Clearview Brain Injury Center | 9.2 mi | ★★★★★ | 4 | 0 |
| Complete Care At Christian Home Llc | 13.8 mi | ★★★★★ | 13 | 0 |
| Hillside Manor | 14 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avina Of Mayville.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.