01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-17 | 15 | 2025-07-17 | 11 |
| Cycle 2 | 2024-06-05 | 6 | 2024-06-05 | 16 |
| Cycle 3 | 2023-05-17 | 8 | 2023-05-17 | 6 |
CMS CCN 5252702026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Avina Of Fond Du Lac
115 E Arndt St · Fond Du Lac, WI 54935 · Fond Du Lac County
Certified beds50CMS provider file
Recent citation rows62current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
62 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 15 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-22 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-05-13 · complaint2026-04-22 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-05-13 · complaint2026-02-11 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2026-02-16 · complaint2026-01-05 · HEALTHF0551Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Correction field: Deficient, Provider has date of correction · 2026-01-23 · complaint2026-01-05 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-06 · complaint2026-01-05 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-01-23 · complaint2025-07-17 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2025-08-052025-07-17 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2025-08-112025-07-17 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-07-222025-07-17 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-08-042025-07-17 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2025-07-222025-07-17 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-08-062025-07-17 · HEALTHF0727Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-112025-07-17 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-07-232025-07-17 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-08-262025-07-17 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2025-07-232025-07-17 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-07-182025-07-17 · FIREK0522Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have an externally vented heating system.
Correction field: Deficient, Provider has date of correction · 2025-07-1803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-10-19 | Fine | $7,446 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- REBEL, IGORIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST20% · since 12/01/2017
- TOPPER, AARONIndividual · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 12/01/2017
- TOPPER, AARONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2017
- RHODE, ROSALINDAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/22/2021
- WEBER, LISAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2021
- REBEL, IGORIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2017
- RHODE, ROSALINDAIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/29/2025
- TOPPER, AARONIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2017
- WEBER, LISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/30/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.72per resident day
RN hours0.40per resident day
Weekend nurse hours3.16per resident day
Staff turnover37.8%CMS reported field
06 / LOCAL RECORDS
Open the Fond Du Lac ledger →Other published facilities nearby
Avina On Division50 beds · CMS overall 1/571 citation rowsEdenbrook Of Fond Du Lac90 beds · CMS overall 4/536 citation rowsFond Du Lac Lutheran Home85 beds · CMS overall 3/589 citation rowsHarbor Haven Health & Rehabilitation85 beds · CMS overall 5/521 citation rowsSt Francis Home90 beds · CMS overall 3/547 citation rows