Avina on Division
517 E Division St, Fond Du Lac, WI 54935 · Fond Du Lac County · 50 certified beds · avg 35 residents/day · certified since Aug 24, 1993
Part of chain: AVINA HEALTHCARE (9 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Mar 28, 2026 · F-0727 · triggered by a complaint
The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Why it matters: Registered nurses handle the most complex care decisions — without enough RN coverage, serious health changes can be missed.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: May 15, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 28, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 23, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 28, 2026 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 23, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (42)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 30, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Mar 28, 2026 | ▲ L · Immediate jeopardy, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Mar 28, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 28, 2026 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 28, 2026 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Mar 28, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Mar 28, 2026 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Mar 28, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| May 21, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 21, 2025 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| May 21, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 21, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 21, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 18, 2024 | C · Minimal risk, facility-wide | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Mar 27, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Mar 27, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 27, 2024 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 27, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 27, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Mar 7, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Mar 7, 2023 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Mar 7, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 7, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Mar 7, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (12 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 0 | F |
| 2024 | 13 | 0 | F |
| 2025 | 5 | 0 | F |
| 2026 | 11 | 3 | L ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
0 fines totaling $0, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 28, 2026 | Payment Denial | 15 days from Apr 30, 2026 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.30 | 4.29 | 3.95 | bottom 15% in Wisconsin; bottom 26% in the U.S. |
| Registered Nurse hours | 0.26 | 1.01 | 0.69 | bottom 1% in Wisconsin; bottom 6% in the U.S. |
| Weekend total nurse staffing | 2.69 | 3.84 | 3.50 | bottom 6% in Wisconsin; bottom 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.06 | 0.68 | 0.48 | bottom 1% in Wisconsin; bottom 1% in the U.S. |
| Total nursing staff turnover (%) | 37.5 | 46.9 | 45.8 | top 24% in Wisconsin; top 30% in the U.S. |
| RN turnover (%) | 0.0 | 39.7 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.60, RN 0.29, weekend 2.94. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Brandman, Joseph | Individual | 5% or Greater Direct Ownership Interest | 40% | 10/22/2021 |
| Rebel, Igor | Individual | 5% or Greater Direct Ownership Interest | 20% | 10/22/2021 |
| Brandman, Joseph | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/22/2021 |
| Brandman, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 10/22/2021 |
| Brandman, Joseph | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/22/2021 |
| Brandman, Joseph | Individual | ADP of the SNF | NOT APPLICABLE | 10/22/2021 |
| Rebel, Igor | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/22/2021 |
| Rebel, Igor | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/22/2021 |
| Rebel, Igor | Individual | ADP of the SNF | NOT APPLICABLE | 10/22/2021 |
| Rhode, Rosalinda | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| Rhode, Rosalinda | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2021 |
| Topper, Aaron | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/22/2021 |
| Topper, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 10/22/2021 |
| Topper, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/22/2021 |
| Topper, Aaron | Individual | ADP of the SNF | NOT APPLICABLE | 10/22/2021 |
| Weber, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2021 |
| Weber, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who on your staff manages IV therapy, and what training and monitoring is in place?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Harbor Haven Health & Rehabilitation | 0.2 mi | Fond Du Lac, WI | ★★★★★ | 5/5 | |
| St Francis Home | 0.4 mi | Fond Du Lac, WI | ★★★☆☆ | 3/5 | |
| Edenbrook of Fond Du Lac | 0.6 mi | Fond Du Lac, WI | ★★★★☆ | 4/5 | |
| Avina of Fond Du Lac | 1.0 mi | Fond Du Lac, WI | ★★☆☆☆ | 2/5 | |
| Fond Du Lac Lutheran Home | 1.2 mi | Fond Du Lac, WI | ★★★☆☆ | 3/5 | |
| Hope Health and Rehab | 13.2 mi | Lomira, WI | ★★★★★ | 4/5 | |
| Bethel Home | 18.2 mi | Oshkosh, WI | ★★★★★ | 4/5 | |
| Edenbrook of Oshkosh | 18.8 mi | Oshkosh, WI | ★★★☆☆ | 3/5 | |
| Evergreen Health Center | 18.9 mi | Oshkosh, WI | ★★★★☆ | 4/5 | |
| Eden Rehab Suites and Green House Homes | 19.4 mi | Oshkosh, WI | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525522.