Avina on Division
517 E Division St, Fond du Lac, WI 54935 · All homes in Fond du Lac
Avina on Division, a 50-bed for profit - limited liability company nursing facility in Fond du Lac, WI, holds a 1-star CMS overall rating - below the 3.0-star national average, ranking #304 of 321 rated homes in WI on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 9209216800
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- 1 / 5
- Much below average · CMS overall · nat'l 3.0
- #304 of 321
- In-state rank among rated WI homes
- 3.60
- Below average · nurse hrs/day · nat'l 3.86
- 42
- Inspection findings · 3 serious
If a nursing-home resident is in immediate danger, call 911.
For elder abuse or neglect concerns, contact your state's Adult Protective Services (search "APS" + your state) or call the Eldercare Locator at 1-800-677-1116. For facility advocacy, reach your Long-Term Care Ombudsman. CMS ratings and inspection data below are a research screen, not an emergency channel.
The verdict
Avina on Division, a 50-bed for profit - limited liability company nursing facility in Fond du Lac, WI, holds a 1-star CMS overall rating - below the 3.0-star national average, ranking #304 of 321 rated homes in WI on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
- 1 / 5
- CMS overall · national 3.0
- #304 of 321
- In-state rank among rated WI homes
- 3.60
- Nurse hrs/resident-day · national 3.86
- 42
- Inspection findings · 3 serious
CMS force-curves overall stars within each state; read health, staffing, and quality sub-ratings alongside the headline.
In-state ownership mix · peer inventory
How 323 WI nursing homes split by ownership sector
This facility is recorded as For profit - Limited Liability company. Sector buckets collapse CMS ownership_type into For-profit, Nonprofit, and Government, orthogonal to the RN/LPN/CNA hour bar below.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525522
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 50
- Residents
- 35
- In Hospital
- No
- County
- Fond Du Lac
- Last Inspection
- May 21, 2025
Staffing Data
How the 3.60 total nursing hours per resident-day are staffed:
- RN Hours
- 0.29 (nat'l avg: 0.69)
- LPN Hours
- 1.06
- CNA Hours
- 2.25
- Total Nursing Hours
- 3.60 (nat'l avg: 3.86)
- PT Hours
- 0.02
- Nursing Turnover
- 37.5%
What the CMS Record Reveals About Avina on Division
According to CMS Nursing Home Compare, Avina on Division ranks #304 of 321 rated nursing homes in WI on overall stars (tie-broken by health+staffing+quality, then fewer fines). Avina on Division operates 50 certified beds in Fond du Lac, WI with approximately 35 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars (health inspection 1★ · staffing 1★ · quality 3★).
The inspection file contains 42 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS has not levied any fines or payment denials against this facility. Reported nurse staffing runs 3.60 total hours per resident day (national average 3.86); RN hours specifically are 0.29 per resident day.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Avina on Division falls into a category where comparative context matters. Reported nursing staff turnover at this facility is 37.5% (CMS payroll-based measure).
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify the same record on Medicare.gov Care Compare and with the facility or your state survey agency before making placement decisions.
Deficiency History (42 most recent)
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2026
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.
Category: Resident Rights Deficiencies
Corrected: May 15, 2026
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 15, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 23, 2026
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Apr 23, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 23, 2026
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 23, 2026
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Apr 23, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 23, 2026
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.
Category: Nursing and Physician Services Deficiencies
Corrected: May 15, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 12, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jun 12, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 13, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 12, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: May 29, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 21, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 18, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 20, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 17, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 17, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 27, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 16, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 27, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Mar 27, 2024
Give the resident's representative the ability to exercise the resident's rights.
Category: Resident Rights Deficiencies
Corrected: Apr 16, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 16, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 17, 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.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 19, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 7, 2023
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 7, 2023
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 7, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 7, 2023
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 7, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 7, 2023
Notify 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.
Category: Resident Rights Deficiencies
Corrected: Apr 7, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Apr 7, 2023
Give the resident's representative the ability to exercise the resident's rights.
Category: Resident Rights Deficiencies
Corrected: Apr 7, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 7, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 7, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Apr 7, 2023
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 7, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 9.5% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 4.5% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.4% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 9.7% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 12.2% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.9% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.2% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.9% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.1% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 28.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 96.3% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 20.8% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 91.8% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 70.6% | No |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Mar 28, 2026 | Payment Denial | - |
Nationwide facilities with similar scale or staffing
Two data-derived peer sets for Avina on Division, both outside WI so the neighborhoods are not the same-state geography list below.
Similar bed count
Nearest CMS certified bed counts outside WI (50 beds here).
Similar staffing hours
Nearest CMS adjusted total nurse hours per resident day outside WI (3.30 here).
Nearby Nursing Homes in WI
322 other nursing homes are on record in WI; 6 are shown here.
Abbotsford Health Care Center
Abbotsford, WI
Alden Estates of Countryside, Inc
Jefferson, WI
Alden Meadow Park Hcc
Clinton, WI
American Lutheran Home-Menomonie
Menomonie, WI
American Lutheran Home-Mondovi
Mondovi, WI
Amethyst Health of Algoma
Algoma, WI
Understanding Nursing Home Data
What the CMS records show for Avina on Division
The health, staffing, and quality sub-ratings above often diverge from the CMS overall headline. Use those components and the inspection findings to read the full file, not the overall star alone.
- The WI registry aggregates state averages and the highest-rated homes in this cohort. View WI registry
- Peer homes near 50 beds show how CMS stars vary at a similar scale in WI. Compare a similar-size peer
- CMS publishes separate fields for inspections, nurse staffing hours, and quality measures; the guide explains how each star is computed. How CMS ratings work
CMS refreshes Nursing Home Compare quarterly (current extract: August 2026). PlainNursing describes published records; it does not establish suitability, availability, admissions, or individual outcomes.
Frequently Asked Questions
What is the overall CMS rating for Avina on Division?
Where does Avina on Division rank among nursing homes in WI?
What are the staffing levels at Avina on Division?
How many beds does Avina on Division have?
Does Avina on Division have any deficiencies on record?
Has Avina on Division received any fines or penalties?
Who owns Avina on Division?
When was Avina on Division last inspected?
What quality measures are tracked for Avina on Division?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Verify the same CCN on Medicare.gov Care Compare and with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
