Avina on Division
517 E Division St, Fond du Lac, WI 54935
Avina on Division is a nursing home in Fond du Lac, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 921-6800
- Last standard health inspection
- August 5, 2026 (3 months ago)
- Certified beds
- 50
- Residents per day, on average
- 33.1
- Ownership type
- For profit - Individual
- Legal business name
- Manor of Fond Du Lac LLC
- Chain
- Avina Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (33 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
4 citations
Health inspection on August 5, 2026
CMS lists this as a standard inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for F0684 2 times since 2026.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for F0695 2 times since 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on August 21, 2026.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on August 27, 2026.
CMS has cited this home for F0806 2 times since 2024.
5 citations
Fire safety inspection on August 5, 2026
CMS lists this as a standard inspection.
Citation E0009. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on September 4, 2026.
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on August 21, 2026.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 24, 2026.
CMS has cited this home for K0918 2 times since 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 21, 2026.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 20, 2026.
CMS has cited this home for K0761 2 times since 2025.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
4 citations
Health inspection on April 30, 2026
CMS lists this as a complaint inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0880 3 times since 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 15, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 15, 2026.
Citation F0694. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on May 15, 2026.
Payment stopped
April 30, 2026 (6 months ago)
CMS stopped payment for new admissions from April 30, 2026, for 15 days.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
7 citations
Health inspection on March 28, 2026
CMS lists this as a complaint inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
Citation F0727. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on May 15, 2026.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 23, 2026.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 23, 2026.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 23, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 23, 2026.
CMS has cited this home for F0812 3 times since 2024.
Citation F0835. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on April 23, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 23, 2026.
Fine
March 28, 2026 (7 months ago)
CMS fine of $58,210 on March 28, 2026.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of December 15, 2025
Ownership
CMS lists this home under a new chain.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Name
CMS lists a new name for this home. It was MANOR OF FOND DU LAC.
CMS update of September 24, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
5 citations
Health inspection on May 21, 2025
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 29, 2025.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on June 12, 2025.
CMS has cited this home for F0814 2 times since 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 13, 2025.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on June 12, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 12, 2025.
7 citations
Fire safety inspection on May 21, 2025
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on June 12, 2025.
CMS has cited this home for E0039 2 times since 2024.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 16, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 24, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for K0354 2 times since 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 9, 2025.
CMS has cited this home for K0321 2 times since 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on July 7, 2025.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on June 9, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on November 18, 2024
CMS lists this as a complaint inspection.
Citation F0814. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on November 21, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
12 citations
Health inspection on March 27, 2024
CMS lists this as a standard inspection.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 17, 2024.
Citation F0645. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 16, 2024.
Citation F0551. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give the resident's representative the ability to exercise the resident's rights.
CMS lists it as corrected on April 16, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on March 27, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on March 27, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 16, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on March 27, 2024.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on April 17, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 17, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 20, 2024.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on April 18, 2024.
14 citations
Fire safety inspection on March 27, 2024
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on May 9, 2024.
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on September 30, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 1, 2024.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on April 18, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 18, 2024.
Citation K0911. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on May 6, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 6, 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 17, 2024.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on March 28, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 29, 2024.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on April 20, 2024.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on March 28, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on March 28, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on March 28, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BRANDMAN, JOSEPH5% or greater direct ownership interest · 40% · since 10/22/2021
- REBEL, IGOR5% or greater direct ownership interest · 20% · since 10/22/2021
- BRANDMAN, JOSEPHOperational/managerial control · not applicable · since 10/22/2021
- REBEL, IGOROperational/managerial control · not applicable · since 10/22/2021
- RHODE, ROSALINDAOperational/managerial control · not applicable · since 04/01/2021
- TOPPER, AARONOperational/managerial control · not applicable · since 10/22/2021
- WEBER, LISAOperational/managerial control · not applicable · since 10/01/2021
Questions
When was Avina on Division last inspected?
CMS lists August 5, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Avina on Division have?
CMS lists 33 health citations since March 27, 2024. CMS also calls these deficiencies.
Has Avina on Division been fined?
CMS lists 1 fine in the past three years, $58,210 in total.
What is the CMS star rating of Avina on Division?
Its CMS overall star rating is 1 of 5.
Is Avina on Division a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.