Avina on Division
517 E Division St · Fond Du Lac, WI · 54935 · 9209216800
50 certified beds For profit - Limited Liability company Chain: Avina Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.40 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.36 | 0.55–0.75 |
| Weekend hours / resident-day | 2.96 | ≈ weekday level |
| Nursing turnover / year | 35% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (42 in the current record)
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Potential for harm · D April 30, 2026 · found via complaint
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.
Deficient, Provider has no plan of correction · Resident Rights
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Potential for harm · D April 30, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has no plan of correction · Quality of Life and Care
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Potential for harm · D April 30, 2026 · found via complaint
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Deficient, Provider has no plan of correction · Quality of Life and Care
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Potential for harm · F April 30, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Deficient, Provider has no plan of correction · Infection Control
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Immediate jeopardy · L March 28, 2026 · found via complaint
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.
Corrected April 23, 2026 · Nursing and Physician Services
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Actual harm · G March 28, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 23, 2026 · Quality of Life and Care
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Actual harm · G March 28, 2026 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected April 23, 2026 · Pharmacy Service
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Potential for harm · D March 28, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 23, 2026 · Resident Rights
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Potential for harm · F March 28, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected April 23, 2026 · Nursing and Physician Services
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Potential for harm · F March 28, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 23, 2026 · Nutrition and Dietary
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Potential for harm · F March 28, 2026 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected April 23, 2026 · Administration
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Potential for harm · D May 21, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected June 12, 2025 · Resident Rights
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Potential for harm · D May 21, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 12, 2025 · Pharmacy Service
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Potential for harm · F May 21, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 29, 2025 · Nutrition and Dietary
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Potential for harm · F May 21, 2025
Dispose of garbage and refuse properly.
Corrected June 12, 2025 · Nutrition and Dietary
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Potential for harm · E May 21, 2025
Provide and implement an infection prevention and control program.
Corrected June 13, 2025 · Infection Control
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No harm found · C November 18, 2024 · found via complaint
Dispose of garbage and refuse properly.
Corrected November 21, 2024 · Nutrition and Dietary
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Potential for harm · D March 27, 2024
Give the resident's representative the ability to exercise the resident's rights.
Corrected April 16, 2024 · Resident Rights
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Potential for harm · D March 27, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected March 27, 2024 · Resident Rights
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Potential for harm · D March 27, 2024
Ensure each resident receives an accurate assessment.
Corrected March 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · E March 27, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected April 16, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 27, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 16, 2024 · Quality of Life and Care
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Potential for harm · D March 27, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 27, 2024 · Quality of Life and Care
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Potential for harm · F March 27, 2024
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.
Corrected April 19, 2024 · Nutrition and Dietary
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Potential for harm · D March 27, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected April 17, 2024 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525522 · certified since August 24, 1993. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.