Avina on Division
517 E DIVISION ST, FOND DU LAC, WI 54935 · CCN 525522
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★★☆ 4
- Staffing
- ★★★☆☆ 3
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 50
- Avg residents/day
- 32.5
- Phone
- 9209216800
Inspection history vs Wisconsin & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Wisconsin avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-05-21 | 5 | 9.8 | 9.5 | -4.8 better |
| 2 | 2024-03-27 | 13 | 9.2 | 9.8 | +3.8 worse |
| 3 | 2023-03-07 | 17 | 8.3 | 9.3 | +8.7 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Resident rights | 1 |
| Nutrition and dietary | 2 |
| Pharmacy service | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.76 | 25.8% |
| RN staffing (reported) | 0.42 | 50.0% |
| Total nurse staffing (adjusted) | 4.01 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Chain
- Chain
- AVINA HEALTHCARE
- Facilities in chain
- 8
- Chain avg overall
- 2.80 / 5
Inspection citations (35)
- DF0558Reasonably accommodate the needs and preferences of each resident.2025-05-21 · Health · corrected 2025-06-12
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-05-21 · Health · corrected 2025-06-12
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-05-21 · Health · corrected 2025-05-29
Potential for more than minimal harm
- FF0814Dispose of garbage and refuse properly.2025-05-21 · Health · corrected 2025-06-12
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-05-21 · Health · corrected 2025-06-13
Potential for more than minimal harm
- CF0814Dispose of garbage and refuse properly.2024-11-18 · Health · corrected 2024-11-21
Potential for minimal harm
- DF0551Give the resident's representative the ability to exercise the resident's rights.2024-03-27 · Health · corrected 2024-04-16
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-03-27 · Health · corrected 2024-03-27
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2024-03-27 · Health · corrected 2024-03-27
Potential for more than minimal harm
- EF0645PASARR screening for Mental disorders or Intellectual Disabilities2024-03-27 · Health · corrected 2024-04-16
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-03-27 · Health · corrected 2024-04-16
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-03-27 · Health · corrected 2024-03-27
Potential for more than minimal harm
- CF0732Post nurse staffing information every day.2024-03-27 · Health · corrected 2024-04-18
Potential for minimal harm
- FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2024-03-27 · Health · corrected 2024-04-19
Potential for more than minimal harm
- DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2024-03-27 · Health · corrected 2024-04-17
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-03-27 · Health · corrected 2024-04-17
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-03-27 · Health · corrected 2024-04-17
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-03-27 · Health · corrected 2024-04-20
Potential for more than minimal harm
- DF0551Give the resident's representative the ability to exercise the resident's rights.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- EF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0624Prepare residents for a safe transfer or discharge from the nursing home.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0625Notify 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.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0679Provide activities to meet all resident's needs.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0699Provide care or services that was trauma informed and/or culturally competent.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- FF0727Have 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.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- DF0758Implement 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.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-03-07 · Health · corrected 2023-04-07
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| TOPPER, AARON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 40% | 2021-10-22 |
| BRANDMAN, JOSEPH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 40% | 2021-10-22 |
| REBEL, IGOR | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | 2021-10-22 |
| RHODE, ROSALINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-04-01 |
| TOPPER, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-10-22 |
| WEBER, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-10-01 |
| BRANDMAN, JOSEPH | Individual | CORPORATE OFFICER | — | 2021-10-22 |
| TOPPER, AARON | Individual | CORPORATE OFFICER | — | 2021-10-22 |
| BRANDMAN, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-10-22 |
| REBEL, IGOR | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-10-22 |
Other facilities in FOND DU LAC
| Name | Overall | Beds |
|---|---|---|
| HARBOR HAVEN HEALTH & REHABILITATION | ★★★★★ | 85 |
| EDENBROOK OF FOND DU LAC | ★★★☆☆ | 90 |
| ST FRANCIS HOME | ★★★☆☆ | 90 |
| Avina of Fond du Lac | ★★☆☆☆ | 50 |
| FOND DU LAC LUTHERAN HOME | ★☆☆☆☆ | 85 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.