Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Sun Prairie during CMS and state inspections, most recent first.
A resident with GI diagnoses and chronic diarrhea had repeated watery and loose stools, but nursing assessments were not documented when the change in condition was reported. The resident’s record showed PRN Lomotil use and ongoing bowel changes, while CNA staff said the nurse was updated and RN/LPN staff stated watery stools required assessment, vital signs, abdominal assessment, and documentation. The DON also expected bowel assessment and vital signs, but no additional documentation was provided.
Failure to Verify G-tube Placement Before Feeding: An LPN initiated a resident's water flush and tube feeding without verifying G-tube placement. The resident had a G-tube and orders for enteral feeds with water flushes before and after feeds and medications. The facility policy required placement to be verified before feeding or flushing, and the DON stated placement must be checked prior to water flush and feeding.
Medication error rates exceeded 5% when an RN administered three different eye drops to a resident with glaucoma back-to-back with no wait time between drops. The resident had orders for Latanoprost, Brinzolamide, and Timolol, and the facility policy called for waiting about 5 minutes between eye medications; the RN said she did not know the wait time, and the DON stated 3 to 5 minutes would be expected.
A facility failed to ensure a resident was assessed for self-administration of medications. The resident, moderately cognitively impaired, had physician orders for inhalers but no documented assessment or order to self-administer. Despite this, the resident kept inhalers at the bedside, and LPNs did not ensure proper assessments and orders were completed. The DON confirmed the lack of assessment and orders, resulting in a deficiency.
The facility was cited for deficiencies in food safety and hygiene practices, including improper food storage with water-damaged boxes, dust accumulation above food prep areas, inadequate handwashing due to hot water, and unclean equipment. Additionally, food items lacked proper labeling, contrary to facility policy.
The facility did not maintain a comfortable temperature in the dining room, affecting several residents who were observed wearing blankets or jackets to stay warm. Temperature readings confirmed the room was below the acceptable range. Staff acknowledged the issue, but there was confusion about how to adjust the temperature, and the Nursing Home Administrator was unaware of recent complaints.
The facility failed to accommodate dietary needs and preferences for several residents, resulting in them not receiving appropriate meals. Residents with conditions like GERD and diabetes were served unsuitable food and denied substitutions, leading to skipped meals. Meal preference cards were not properly utilized, and staff were unaware of residents' dietary restrictions. This lack of communication and execution resulted in residents relying on inadequate alternatives.
The facility failed to resolve grievances for two residents regarding missing personal items. Despite reporting the issues to staff and administration, no documentation or follow-up was conducted, violating the facility's grievance policy. The Nursing Home Administrator and Business Office Manager did not effectively communicate or document the grievances, leading to unresolved issues for the residents.
A facility failed to implement timely wound care orders for a resident with multiple pressure injuries. Despite specific instructions from a wound clinic, there was a four-day delay in updating the treatment orders, which changed the frequency of dressing changes. The resident, who was cognitively intact, expressed concerns about the incorrect execution of her treatments. The Director of Nursing acknowledged the delay and the expectation for staff to follow physician orders.
The facility failed to provide individualized care for two residents with PTSD or trauma-related symptoms. One resident with a PTSD diagnosis and another with trauma indicators lacked care plans addressing their specific needs. Staff interviews revealed a lack of awareness and training regarding these residents' conditions, leading to inadequate trauma-informed care.
A resident with a complex medical history experienced severe bleeding of unknown origin, leading to a change of condition and death. The incident was not reported to the State Agency, as required. Interviews revealed that the DON and NHA did not consider or know about the reporting requirement.
A resident with a complex medical history experienced severe bleeding and a significant change of condition, leading to death. Despite informal discussions and a timeline created by staff, the facility did not conduct a thorough investigation into the incident.
A resident with a complex medical history experienced a significant change of condition and subsequently passed away. The facility failed to document the change of condition, emergency measures taken, and the resident's passing in the medical record, which constitutes a deficiency in maintaining complete and accurate medical records.
Failure to Assess and Document Resident’s Watery Stools
Penalty
Summary
The facility did not ensure that a resident with a history of non-infective gastroenteritis, colitis, and gastroparesis received nursing assessment and monitoring for a change in condition when watery stools were occurring. The resident, who was cognitively intact, reported being ill with emesis and diarrhea since January 1, 2026. The care plan addressed chronic diarrhea and included giving medications as ordered and monitoring/documenting side effects and effectiveness. The physician order included Diphenoxylate-Atropine (Lomotil) as needed for diarrhea, and the bowel record showed repeated watery and loose stools over several days, with only two documented administrations of Lomotil noted as effective. After loose watery stools were documented and the NP was updated, there was no documentation of a nursing assessment. Surveyor interviews showed CNA staff reported the resident had been having loose, watery stools and that the nurse had been updated. RN and LPN staff stated that watery stools required assessment, including abdominal assessment, bowel sounds, vital signs, and documentation in progress notes, with continued assessment and physician updates if the condition continued. The DON also stated that bowel assessment and vital signs would be expected for the resident, but no additional documentation was provided by the facility.
Failure to Verify G-tube Placement Before Feeding
Penalty
Summary
The facility did not ensure appropriate care and services were provided for a resident who received nutrition and medications by enteral means. R5 was admitted with diagnoses including encounter for surgical aftercare following surgery on the digestive system, moderate protein-calorie malnutrition, and gastrostomy status, and had physician orders for enteral feedings four times daily with water flushes before and after feeds and medications. During observation on 1/6/26 at 11:54 AM, LPN C initiated R5's water flush and tube feeding without verifying placement of the gastrostomy tube. The surveyor did not observe any placement check before the flush and feeding were started. When questioned after the observation, LPN C stated that tube placement is checked with instillation of air and auscultation, but also stated that placement was not checked before R5's water flush and tube feeding. The facility's policy required proper placement and functioning of feeding tubes to be verified before beginning a feeding, flushing the tube, or administering medications, and for gastrostomy tubes specifically, to check that the enteral retention device is properly approximated to the abdominal wall and that the tube is not dislodged. The DON stated that placement of the tube needs to be verified prior to water flush and feeding.
Medication pass error rate exceeded 5% due to consecutive eye drops given without wait time
Penalty
Summary
Medication error rates were not kept below 5 percent. Based on observation, interview, and record review, the facility had 3 medication errors in 29 opportunities, affecting 1 of 4 residents included in the medication pass task, for an error rate of 10.34%. The error involved a resident with unspecified glaucoma and type II diabetes mellitus who had a BIMS score of 10, indicating moderate cognitive impairment. During the medication pass, the resident was ordered Latanoprost, Brinzolamide (Azopt), and Timolol eye drops for both eyes. An RN administered the three different eye drops one after another with no wait time between each medication. The facility policy titled Administration of Eye Drops or Ointments stated that if a second medication is required in the same eye, the approximate wait time per manufacturer specifications is usually 5 minutes. When asked how long to wait between eye drops, the RN stated she did not know. The DON stated that a nurse should wait 3 to 5 minutes between consecutive eye drops and confirmed that this would be expected.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined it was appropriate for a resident to self-administer medications. The resident in question, who was moderately cognitively impaired with a BIMS score of 11 out of 15, was admitted with a diagnosis of chronic obstructive pulmonary disease. The resident had physician orders for Fluticasone-Salmeterol and Tiotropium Bromide inhalers, with special instructions to rinse her mouth after use. However, there was no documented assessment or physician order allowing the resident to self-administer these medications. Interviews with facility staff revealed that the resident repeatedly kept the inhalers at her bedside despite not having the necessary orders to do so. LPNs involved in the resident's care were aware of the situation but did not ensure that the appropriate assessments and orders were completed. The Director of Nursing confirmed that the resident had not been assessed for self-administration, nor were there any physician orders to allow the resident to keep the inhalers at her bedside, leading to a deficiency in the facility's medication administration process.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility was found to have several deficiencies in food storage, preparation, and service that could potentially affect all 40 residents. Observations included frozen drips on the ceiling of the walk-in freezer, with water-damaged boxes of unsealed food such as fish fillets and tater tots. The Dietary Manager (DM) acknowledged the issue but was unsure if the food had been contaminated. Additionally, there was hairlike dust on electrical cords and piping above the food preparation and serving areas, which could potentially dislodge into open food. The Nursing Home Administrator (NHA) confirmed the potential risk of dust contamination. Hand hygiene practices were also deficient, with staff washing their hands for less than the required 20 seconds due to excessively hot water, as indicated by a caution sign above the sink. The meat slicer was found stored unclean with dried meat particles, and food items in the kitchen and kitchenette lacked proper labeling with expiration, open, or use-by dates. The facility's policy required food brought from outside sources to be labeled with the resident's name and date, but this was not adhered to, as observed with undated and unlabeled food items in the refrigerator and freezer.
Facility Fails to Maintain Comfortable Temperature in Dining Room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the consistently cold temperatures in the dining room. This deficiency affected six residents, including those with varying levels of cognitive impairment, who were observed wearing blankets or jackets to stay warm. The residents consistently reported that the dining room was cold, and this was corroborated by temperature readings taken by the surveyor, which showed temperatures ranging from 64 to 67 degrees Fahrenheit, below the facility's acceptable range of 71 to 81 degrees Fahrenheit. The facility's staff, including a CNA and the Maintenance Director, acknowledged the cold conditions in the dining room. The CNA mentioned being unaware of how to adjust the temperature, while the Maintenance Director was unsure which unit controlled the dining room's temperature. Despite the residents' complaints and the Resident Council meeting minutes indicating awareness of the issue, the Nursing Home Administrator claimed no recent concerns had been raised. This lack of action and awareness contributed to the ongoing discomfort experienced by the residents.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, and preferences, resulting in several residents not receiving appropriate meals. This deficiency was observed in three sampled residents and one supplemental resident. The facility's policy required meal identification and preference cards to be used to ensure correct diets and preferences were honored, but these were not properly utilized. For instance, one resident with GERD was served spicy food, which they could not tolerate, and was denied a substitution, leading them to skip dinner and consume candy instead. Another resident with diabetes and GERD also reported being served spicy food, which they could not eat, and was similarly denied a substitution. This resident had to rely on snacks in their room for dinner. The surveyor found that the dislike sections on the meal tickets for these residents were blank, indicating a lack of communication regarding their dietary needs and preferences. Additionally, a third resident reported being served food with cheese, which they disliked, although they were usually able to get a substitution. Interviews with dietary staff and the nursing home administrator revealed a lack of awareness and communication regarding residents' dietary restrictions and preferences. The dietary manager and aides indicated that residents could request substitutions, but this was not consistently communicated or executed. The nursing home administrator acknowledged the issue and agreed that it was inappropriate for residents, especially those with diabetes, to go without meals. The facility's failure to provide appropriate meals and substitutions led to residents skipping meals and relying on inadequate alternatives.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for two residents, R48 and R30, as required by their grievance policy. R48 reported missing personal items, including a pair of pants and socks, to the Nursing Home Administrator (NHA A) but did not receive a follow-up or resolution. Despite assurances from NHA A that the issue would be addressed, there was no documentation of the grievance or any investigation conducted. Similarly, R30 expressed concerns about missing clothes and other personal items, which were reported to the administration by staff members, but no action was taken to resolve these grievances. The facility's grievance policy mandates that grievances, whether verbal or written, should be documented and investigated promptly, with efforts made toward resolution within seven days. However, in the case of R30, the Licensed Practical Nurse (LPN H) and Housekeeping Manager (HSK D) acknowledged the resident's concerns but did not have any records or logs of the missing items. NHA A admitted that the facility did not follow its grievance policy, as grievances were not documented, and no follow-up was conducted because the items were usually found immediately. In the case of R48, the Business Office Manager (BOM C) failed to communicate with NHA A about the returned payment intended for R48, which was undeliverable due to an incorrect address. Despite multiple attempts to contact R48, the issue remained unresolved, and the cash was kept in the office. The lack of communication and documentation between BOM C and NHA A contributed to the failure to resolve R48's grievance, highlighting a breakdown in the facility's grievance process.
Failure to Implement Timely Wound Care Orders
Penalty
Summary
The facility failed to implement professional standards of practice to prevent pressure injuries from developing or worsening and to promote healing for a resident with multiple pressure injuries. The resident, who was admitted with a Stage IV right ischial pressure ulcer and a Stage IV sacrococcygeal pressure injury, had specific wound care instructions from a wound clinic. These instructions included washing the wound with antibacterial soap, using Dakin's solution, and performing dressing changes. However, there was a delay in updating the treatment orders from the wound clinic, which changed the frequency of dressing changes from twice daily to once daily. The facility did not enter and begin following the new orders until four days after they were issued. The resident, who was cognitively intact, expressed concerns about the incorrect execution of her treatments. Despite the facility's Director of Nursing acknowledging that staff should follow physician orders and that the wound clinic's instructions should not be altered, the new orders were not implemented in a timely manner. This delay in updating and executing the wound care orders contributed to the deficiency in providing appropriate pressure ulcer care, as the facility did not adhere to the prescribed treatment plan promptly.
Failure to Provide Individualized Care for Residents with PTSD
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized treatment and services for residents with mental disorders, psychosocial adjustment difficulties, or a history of trauma and PTSD. This deficiency was identified for two residents, R37 and R30, out of a sample of 18. R37, who was admitted with a diagnosis of PTSD, did not have a care plan that addressed personalized potential triggers or specific interventions related to his PTSD. Despite being cognitively intact, as indicated by a BIMS score of 15, R37's care plan only mentioned general feelings of sadness, anxiety, and despair without focusing on his PTSD diagnosis. Interviews with R37's representative revealed that R37 was experiencing significant mental distress, which was not adequately addressed in his care plan. Similarly, R30, who did not have a formal PTSD diagnosis but had a history of traumatic experiences indicative of PTSD symptoms, also lacked a care plan that addressed his specific needs. R30's care plan was generic and did not include personalized interventions or potential triggers related to his trauma history. R30 expressed frustration during an interview, stating that the staff were not adequately trained to handle residents with issues like his. The Brief Trauma Questionnaire completed by R30 highlighted several traumatic experiences, yet these were not reflected in his care plan. Interviews with facility staff, including CNAs and the Nursing Home Administrator, revealed a lack of awareness and training regarding the residents' PTSD and trauma-related needs. The CNAs were unsure of the residents' PTSD status and relied on care plans for guidance, which were insufficiently detailed. The Nursing Home Administrator acknowledged the oversight and agreed that both residents required personalized care plans with a focus on their trauma and PTSD symptoms. This lack of individualized care planning resulted in staff being unaware of how to provide trauma-informed care to these residents.
Failure to Report Severe Bleeding and Change of Condition Leading to Death
Penalty
Summary
The facility did not ensure that all injuries of unknown origin or serious bodily injury were reported to the State Agency for one of the sampled residents. The resident, who had a complex medical history including femoral artery bypass surgery and amputation of right foot digits, was discovered to have severe bleeding of unknown origin which led to a change of condition and subsequent death. Despite the severity of the incident, it was not reported to the State Agency as required. The resident had complained of pain and had elevated blood pressure earlier in the day, and later experienced a significant change in condition. During an occupational therapy session, the resident appeared off, and subsequent checks revealed low blood pressure and unresponsiveness. Emergency measures were taken, including the administration of Narcan and CPR, but the resident passed away due to hemorrhagic femoral bypass graft incision. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that neither had considered reporting the incident to the State Agency. The DON admitted to not thinking about reporting, and the NHA stated they did not know it should be reported. The failure to report the severe bleeding of unknown origin and the change of condition leading to death constitutes a deficiency in the facility's compliance with reporting requirements.
Failure to Investigate Severe Bleeding Leading to Resident's Death
Penalty
Summary
The facility did not ensure that all injuries of unknown origin or serious bodily injury were thoroughly investigated for a resident who experienced a significant change of condition and subsequent death. The resident, who had a complex medical history including femoral artery bypass surgery, amputation, and multiple chronic conditions, complained of pain and had elevated blood pressure in the morning. Despite receiving pain medication and having his condition monitored, the resident's condition deteriorated in the afternoon. Occupational Therapy noted the resident seemed off, and later, the resident became unresponsive. During the emergency response, it was discovered that the resident had severe bleeding from the femoral bypass graft incision, which led to his death. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that while staff discussed the incident informally and created a timeline, a formal investigation was not conducted. The timeline was based on staff interviews but was not documented as a thorough investigation. The event was unexpected, and the resident's death was untimely, highlighting the need for a comprehensive investigation into the severe bleeding and change of condition that led to the resident's death.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility did not maintain complete and accurately documented medical records for a resident who experienced a significant change of condition and subsequently passed away. The resident, who had a complex medical history including femoral artery bypass surgery, amputation, and multiple chronic conditions, was noted to have increased pain and was administered pain medication. However, the medical record did not document the resident's change of condition, the facility's actions, or the resident's passing. The last progress note indicated the resident was alert and oriented, with no acute distress, but did not include any information about the critical events that followed. On the day of the incident, the resident's condition deteriorated while being attended by occupational and physical therapists. The resident exhibited signs of distress, including a low blood pressure reading and unresponsiveness, which prompted the staff to take emergency measures. Despite administering Narcan and attempting cardiopulmonary resuscitation, the resident passed away due to a hemorrhagic femoral bypass graft incision. The Director of Nursing acknowledged that the documentation of these events was not included in the resident's medical record, which constitutes a deficiency in maintaining complete and accurate medical records.
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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.
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Nursing homes near Sun Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Prairie Senior Living | 1.2 mi | ★★★★★ | 23 | 0 |
| Oakwood Village East Health And Rehab Center | 2.7 mi | ★★★★★ | 2 | 1 |
| Oak Park Nursing And Rehab Center | 6.7 mi | ★★★★★ | 41 | 3 |
| Madison Health And Rehabilitation Center | 6.9 mi | — | 39 | 0 |
| Capitol Lakes Health Center | 10.5 mi | ★★★★★ | 11 | 1 |
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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.