Avina Of Sun Prairie

Inspection findings

1. Jan 8, 2026 Fire Safety · 10 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Feb 24, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected Feb 12, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Feb 8, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Feb 8, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 8, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     Corrected Feb 26, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Feb 26, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 26, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Feb 26, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Feb 26, 2026 · CMS fire safety

2. Jan 4, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Jan 24, 2025 · CMS health inspection

3. Aug 22, 2024 Health · 13 findings
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     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.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0742 Quality of Life and Care Deficiencies

     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.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0131 Construction Deficiencies

     Meet requirements for sections of health care facilities separated by fire resistive construction.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0300 Egress Deficiencies

     Meet other general requirements that are deficient.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 20, 2024 · CMS fire safety

4. Apr 3, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Apr 22, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Apr 22, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Apr 22, 2024 · CMS health inspection

5. Apr 27, 2023 Health · 7 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 25, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0637 Resident Assessment and Care Planning Deficiencies

     Assess the resident when there is a significant change in condition

     Corrected May 25, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected May 25, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected May 25, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 25, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 25, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected May 25, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• REBEL, IGOR — adp of the snf, NOT APPLICABLE, since 12/01/2017
• REBEL, IGOR — operational/managerial control, NOT APPLICABLE, since 12/01/2017
• REBEL, IGOR — managing control - governing body, NOT APPLICABLE, since 12/01/2017
• REBEL, IGOR — 5% or greater direct ownership interest, 20%, since 12/01/2017
• SIDHU, SARFRAZ — operational/managerial control, NOT APPLICABLE, since 10/01/2021
• SIDHU, SARFRAZ — adp of the snf, NOT APPLICABLE, since 10/01/2021
• TOPPER, AARON — operational/managerial control, NOT APPLICABLE, since 12/01/2017
• TOPPER, AARON — adp of the snf, NOT APPLICABLE, since 12/01/2017
• TOPPER, AARON — managing control - governing body, NOT APPLICABLE, since 12/01/2017
• VANDER MEER, PETER — operational/managerial control, NOT APPLICABLE, since 05/29/2024
• VANDER MEER, PETER — adp of the snf, NOT APPLICABLE, since 05/29/2024