Federal Nursing-Home Survey Record
Avina on Division
Does Avina on Division have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Avina on Division (CCN 525522), in Fond du Lac, WI, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 12 deficiencies; the most serious carries scope/severity L on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. The most recent federal survey on file is dated 2025-05-21. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
At its most recent federal inspection, CMS cited this facility for an Immediate Jeopardy deficiency.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.0
Deficiency timeline — full federal history
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that residents are free from significant medication errors.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
Provide and implement an infection prevention and control program.
Reasonably accommodate the needs and preferences of each resident.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
26 citations from earlier inspection cycles — historical, not current (expand)
Dispose of garbage and refuse properly.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
PASARR screening for Mental disorders or Intellectual Disabilities
Provide safe and appropriate respiratory care for a resident when needed.
Give the resident's representative the ability to exercise the resident's rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure each resident receives an accurate assessment.
Post nurse staffing information every day.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
PASARR screening for Mental disorders or Intellectual Disabilities
Provide activities to meet all resident's needs.
Provide enough food/fluids to maintain a resident's health.
Provide care or services that was trauma informed and/or culturally competent.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
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.
Give the resident's representative the ability to exercise the resident's rights.
Document what happened
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