Nursing HomeInspections

Avina on Division

Nursing home in Fond du Lac, WI

Medicare & Medicaid certified1★ overall (CMS)

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Public-record details

Address
517 E Division St, Fond du Lac, WI 54935
Phone
(920) 921-6800
Listed under
For-profit
Medicare CCN
525522
Overall star rating
1 of 5 ★☆☆☆☆
Health inspection rating
1 of 5
Staffing rating
1 of 5
Quality measures rating
3 of 5
Certified beds
50
Average residents per day
35
Ownership
For-profit, limited Liability company
Legal business name
Manor of Fond Du Lac LLC
Chain
Avina Healthcare (9 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
Aug 24, 1993
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Sprinklers in all required areas
Yes

CMS certification number 525522. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: May 21, 2025. CMS lists 42 health citations for this facility across its last three standard inspection cycles and complaint inspections (Mar 7, 2023 to Apr 30, 2026): 12 from complaint inspections, 3 at the “actual harm” level or higher, including 1 at “immediate jeopardy”.

InspectionCitationSeverity
Apr 30, 2026Honor 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.
Resident Rights · complaint inspection
D
Potential for more than minimal harm, isolated
Apr 30, 2026Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care · complaint inspection
D
Potential for more than minimal harm, isolated
Apr 30, 2026Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care · complaint inspection
D
Potential for more than minimal harm, isolated
Apr 30, 2026Provide and implement an infection prevention and control program.
Infection Control · complaint inspection
F
Potential for more than minimal harm, widespread
Mar 28, 2026Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights · complaint inspection
D
Potential for more than minimal harm, isolated
Mar 28, 2026Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services · complaint inspection
F
Potential for more than minimal harm, widespread
Mar 28, 2026Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary · complaint inspection
F
Potential for more than minimal harm, widespread
Mar 28, 2026Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration · complaint inspection
F
Potential for more than minimal harm, widespread
Mar 28, 2026Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care · complaint inspection
G
Actual harm, isolated
Mar 28, 2026Ensure that residents are free from significant medication errors.
Pharmacy Service · complaint inspection
G
Actual harm, isolated
Mar 28, 2026Have 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.
Nursing and Physician Services · complaint inspection
L
Immediate jeopardy, widespread
May 21, 2025Reasonably accommodate the needs and preferences of each resident.
Resident Rights
D
Potential for more than minimal harm, isolated

Showing the 12 most recent of 42. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records 0 fines totalling $0 and 1 denial of Medicare payment for new admissions in the last three years.

Mar 28, 2026Payment denial for 15 days from Apr 30, 2026

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.60 hours
Registered nurse (RN) time per resident per day
0.29 hours
Nurse aide time per resident per day
2.25 hours
Total nurse staffing on weekends
2.94 hours
Nursing staff turnover (yearly)
38%
Administrators who left in the past year
0

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.

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