Wisconsin › Fond Du Lac County › Fond Du Lac
Avina On Division
517 E Division St, Fond Du Lac, WI 54935
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Avina On Division is a For-profit, limited liability company nursing home in Fond Du Lac, Wisconsin, certified for 50 beds and caring for about 35 residents a day.
CMS gives it 1 of 5 stars overall, below the Wisconsin median of 3; the health inspection rating is 1, staffing 1 and quality measures 3.
Inspectors recorded 42 health deficiencies across the three most recent survey cycles (16, 13, 13 by cycle, most recent first), 3 of them at the actual-harm or immediate-jeopardy level. That is 84.0 per 100 beds, more than the state median of 31.8.
CMS lists 1 penalty in the period covered: no fines and 1 payment denial.
Reported nurse staffing is 3.6 hours per resident per day (0.3 RN), close to the Wisconsin median of 4.0; nursing staff turnover is 37.5%.
Compared with county, state and nation
| Measure | This facility | Fond Du Lac Co. median | Wisconsin median | US average |
|---|---|---|---|---|
| Overall star rating | 1 | 3 | 3 | 3.0 |
| Health citations, 3 cycles | 42 | 26 | 21 | 28.7 |
| Citations per 100 beds | 84.0 | 34.0 | 31.8 | 26.8 |
| Total nurse hours per resident day | 3.6 | 3.6 | 4.0 | 3.9 |
| RN hours per resident day | 0.3 | 0.8 | 0.9 | 0.7 |
| Nursing staff turnover | 37.5% | 39.5% | 46.2% | 45.8% |
| Fines listed | $0 | $7,446 | $0 | — |
County and state figures are medians across facilities (7 in the county, 323 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Wisconsin average per facility for the same cycle, as published by CMS. Standard health survey dates: 21 May 2025, 27 Mar 2024.
Severity mix: L ×1 G ×2 D ×23 E ×5 F ×9 C ×2
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 30 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | F | Complaint investigation | 15 May 2026 |
| 30 Apr 2026 | F0584 | 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. | D | Complaint investigation | 15 May 2026 |
| 30 Apr 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | 15 May 2026 |
| 30 Apr 2026 | F0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | Complaint investigation | 15 May 2026 |
| 28 Mar 2026 | F0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | L | Complaint investigation | 15 May 2026 |
| 28 Mar 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | Complaint investigation | 23 Apr 2026 |
| 28 Mar 2026 | F0760 | Ensure that residents are free from significant medication errors. | G | Complaint investigation | 23 Apr 2026 |
| 28 Mar 2026 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint investigation | 23 Apr 2026 |
| 28 Mar 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint investigation | 23 Apr 2026 |
| 28 Mar 2026 | F0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F | Complaint investigation | 23 Apr 2026 |
| 28 Mar 2026 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint investigation | 23 Apr 2026 |
| 21 May 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 29 May 2025 |
| 21 May 2025 | F0814 | Dispose of garbage and refuse properly. | F | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 13 Jun 2025 |
| 21 May 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 12 Jun 2025 |
| 18 Nov 2024 | F0814 | Dispose of garbage and refuse properly. | C | Complaint investigation | 21 Nov 2024 |
| 27 Mar 2024 | F0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | F | Standard survey | 19 Apr 2024 |
| 27 Mar 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 17 Apr 2024 |
| 27 Mar 2024 | F0645 | PASARR screening for Mental disorders or Intellectual Disabilities | E | Standard survey | 16 Apr 2024 |
| 27 Mar 2024 | F0551 | Give the resident's representative the ability to exercise the resident's rights. | D | Standard survey | 16 Apr 2024 |
| 27 Mar 2024 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard survey | 27 Mar 2024 |
| 27 Mar 2024 | F0641 | Ensure each resident receives an accurate assessment. | D | Standard survey | 27 Mar 2024 |
| 27 Mar 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 16 Apr 2024 |
| 27 Mar 2024 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard survey | 27 Mar 2024 |
| 27 Mar 2024 | F0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Standard survey | 17 Apr 2024 |
| 27 Mar 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard survey | 17 Apr 2024 |
| 27 Mar 2024 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 20 Apr 2024 |
| 27 Mar 2024 | F0732 | Post nurse staffing information every day. | C | Standard survey | 18 Apr 2024 |
| 7 Mar 2023 | F0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0551 | Give the resident's representative the ability to exercise the resident's rights. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0679 | Provide activities to meet all resident's needs. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0699 | Provide care or services that was trauma informed and/or culturally competent. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D | Standard survey | 7 Apr 2023 |
| 7 Mar 2023 | F0758 | 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. | D | Standard survey | 7 Apr 2023 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 28 Mar 2026 | Payment denial | — | 15 days |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Wisconsin average. Turnover: nursing staff 37.5%, RNs —; 0 administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 9.5% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.8% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 4.5% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.4% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 9.7% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 12.2% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.9% | 14.4% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, limited liability company. Legal business name: Manor Of Fond Du Lac Llc. Chain: Avina Healthcare (9 facilities).
No organisations are listed in the CMS ownership record for this facility.
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Fond Du Lac County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Harbor Haven Health & Rehabilitation | Fond Du Lac | 85 | 5 | 5 | 5 | 2 | 2.4 | — | 21 Feb 2024 |
| Edenbrook of Fond Du Lac | Fond Du Lac | 90 | 4 | 4 | 3 | 14 | 15.6 | $9K | 11 Jun 2025 |
| Fond Du Lac Lutheran Home | Fond Du Lac | 85 | 3 | 3 | 2 | 43 | 50.6 | $9K | 14 May 2026 |
| St Francis Home | Fond Du Lac | 90 | 3 | 3 | 3 | 26 | 28.9 | — | 1 Apr 2026 |
| Whispering Pines Nursing and Rehab, LLC | Ripon | 50 | 3 | 3 | 3 | 17 | 34.0 | $13K | 9 Jun 2026 |
| Avina of Fond Du Lac | Fond Du Lac | 50 | 2 | 2 | 2 | 29 | 58.0 | $7K | 22 Apr 2026 |
All 7 facilities in Fond Du Lac County
Questions and answers
How many deficiencies has Avina On Division been cited for?
42 health deficiencies across the three most recent survey cycles, 3 at the actual-harm or immediate-jeopardy level. The Wisconsin median is 21 per facility.
Has Avina On Division been fined?
CMS lists no fines against the facility in the period covered.
How does staffing at Avina On Division compare?
Reported total nurse staffing is 3.6 hours per resident per day against a Wisconsin median of 4.0 and a national average of 3.9.
Who operates Avina On Division?
It is part of the Avina Healthcare chain. Ownership type is for-profit, limited liability company. Individual owners and managers are not listed on this site.
When was Avina On Division last inspected?
The most recent survey or investigation in the CMS record is dated 30 Apr 2026; the most recent standard health survey was 21 May 2025.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.