Nursing homeActive
Avina on Division
517 E Division St, Fond du Lac, WI 54935920921680050 certified beds · 35 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
6
since 2023
Deficiencies
42
● 2● 37● 3
Penalties · 3 yrs
—
1 action
Last survey
2026-04-30
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 1
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Wisconsin Division of Quality Assurance · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-04-30 | Complaint | 040 | CMS-2567 (Care Compare) | — |
| 2026-03-28 | Complaint | 043 | CMS-2567 (Care Compare) | — |
| 2025-05-21 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2024-11-18 | Complaint | 100 | CMS-2567 (Care Compare) | — |
| 2024-03-27 | Standard | 1110 | CMS-2567 (Care Compare) | — |
| 2023-03-07 | Standard | 0130 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Wisconsin Division of Quality Assurance publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-15Record 525522-20260430-F584
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-15Record 525522-20260430-F686
F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-15Record 525522-20260430-F694
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-05-15Record 525522-20260430-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-04-23Record 525522-20260328-F684
F727Have 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.Scope/severity LHarm
Staffing
Widespread; immediate jeopardy to resident health or safety.Corrected 2026-05-15Record 525522-20260328-F727
F760Ensure that residents are free from significant medication errors.Scope/severity GHarm
Medication
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-04-23Record 525522-20260328-F760
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-23Record 525522-20260328-F550
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-04-23Record 525522-20260328-F725
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-04-23Record 525522-20260328-F812
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-04-23Record 525522-20260328-F835
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-12Record 525522-20250521-F558
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-12Record 525522-20250521-F755
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-05-29Record 525522-20250521-F812
F814Dispose of garbage and refuse properly.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-06-12Record 525522-20250521-F814
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-13Record 525522-20250521-F880
F814Dispose of garbage and refuse properly.Scope/severity CPaperwork
Food & nutrition
Widespread; potential for minimal harm.Corrected 2024-11-21Record 525522-20241118-F814
F551Give the resident's representative the ability to exercise the resident's rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-16Record 525522-20240327-F551
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-27Record 525522-20240327-F580
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-27Record 525522-20240327-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-16Record 525522-20240327-F645
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-16Record 525522-20240327-F689
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-27Record 525522-20240327-F695
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-19Record 525522-20240327-F801
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-17Record 525522-20240327-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-17Record 525522-20240327-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-17Record 525522-20240327-F842
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-20Record 525522-20240327-F880
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2024-04-18Record 525522-20240327-F732
F551Give the resident's representative the ability to exercise the resident's rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F551
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F582
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F623
F625Notify 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F625
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F645
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F679
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F692
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F699
F727Have 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.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F727
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F740
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F758
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-04-07Record 525522-20230307-F812
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2026-03-28 | Denial of payment for new admissions Payment denial for 15 days, from 2026-04-30 | — | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.29
Facility
Wisconsin
National
Wisconsin 0.99 · National 0.69
Total nurse hours per resident day3.60
Facility
Wisconsin
National
Wisconsin 4.21 · National 3.86
Weekend total nurse hours2.94
Facility
Wisconsin
National
Wisconsin 3.77 · National 3.42
Total nursing staff turnover38%
Facility
Wisconsin
National
Wisconsin 47% · National 46%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Wisconsin | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 12.2% | 5.0% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 5.4% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 13.9% | 15.8% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 4.5% | 2.7% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 9.5% | 16.1% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.2% | 5.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 28.4% | 16.9% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Brandman, Joseph Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 40% | — | — |
| Rebel, Igor Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | — | — |
| Brandman, Joseph Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Rebel, Igor Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Rhode, Rosalinda Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Topper, Aaron Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Weber, Lisa Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Brandman, Joseph Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Brandman, Joseph Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Brandman, Joseph Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Rebel, Igor Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Rebel, Igor Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Rhode, Rosalinda Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Topper, Aaron Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Topper, Aaron Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Topper, Aaron Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Weber, Lisa Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Avina Healthcare — 9 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wisconsin.
No county cost figures on file for Fond Du Lac.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Harbor Haven Health & Rehabilitation Fond du Lac | 0.2 mi | 2025-04-23 | 020 |
| St Francis Home Fond du Lac | 0.4 mi | 2026-04-01 | 0260 |
| Edenbrook of Fond Du Lac Fond Du Lac | 0.6 mi | 2025-06-11 | 0111 |
| Avina of Fond du Lac Fond du Lac | 1.0 mi | 2026-04-22 | 0261 |
| Fond du Lac Lutheran Home Fond du Lac | 1.2 mi | 2026-05-14 | 1292 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |