Avina on Division

517 E DIVISION ST, FOND DU LAC, WI 54935

Facility Assessment This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.

Below the repealed 0.55 hr RN benchmark — average inspection record.

Quality Breakdown

RN Staffing Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.	0.42 — Below the repealed 0.55 hr benchmark
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles) Violations found during federal inspections, with how many remain open and how many involved actual harm.	Total 31 Outstanding 0 Actual harm or worse (G–L) 0
CMS Ratings Overall and Staffing quality ratings from CMS (1-5 stars).	Quality: ★★★★☆ (4/5) Staffing: ★★★☆☆ (3/5)
NursingHomeGrade Score	63/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

31 deficiencies found. 31 corrected. None involved actual harm.

Most recent inspection (May 21, 2025)

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 13, 2025

F Potential harm — widespread F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 29, 2025

F Potential harm — widespread F0814 Status: Corrected

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025

D Potential harm — isolated F0558 Status: Corrected

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025

Inspection cycle 2 (March 27, 2024)

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 20, 2024

C No harm — widespread F0732 Status: Corrected

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected April 18, 2024

C No harm — widespread F0814 Status: Corrected

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 21, 2024

F Potential harm — widespread F0801 Status: Corrected

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 19, 2024

D Potential harm — isolated F0806 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2024

F Potential harm — widespread F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2024

D Potential harm — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 16, 2024

D Potential harm — isolated F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 27, 2024

D Potential harm — isolated F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 27, 2024

E Potential harm — pattern F0645 Status: Corrected

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 16, 2024

D Potential harm — isolated F0842 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2024

D Potential harm — isolated F0551 Status: Corrected

Give the resident's representative the ability to exercise the resident's rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 16, 2024

D Potential harm — isolated F0580 Status: Corrected

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 27, 2024

Inspection cycle 3 (March 7, 2023)

F Potential harm — widespread F0727 Status: Corrected

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

E Potential harm — pattern F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

D Potential harm — isolated F0758 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

D Potential harm — isolated F0679 Status: Corrected

Provide activities to meet all resident's needs.