01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-21 | 16 | 2025-05-21 | 7 |
| Cycle 2 | 2024-03-27 | 13 | 2024-03-27 | 14 |
| Cycle 3 | 2023-03-07 | 13 | 2023-03-07 | 8 |
CMS CCN 5255222026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Avina On Division
517 E Division St · Fond Du Lac, WI 54935 · Fond Du Lac County
Certified beds50CMS provider file
Recent citation rows71current 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
71 rows in the current release
3 rows carry G–L scope/severity codes; 1 carry J–L. 14 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-30 · 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 · 2026-05-15 · complaint2026-04-30 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-04-30 · HEALTHF0694Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-04-30 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-03-28 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-04-23 · complaint2026-03-28 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-23 · complaint2026-03-28 · HEALTHF0725Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2026-04-23 · complaint2026-03-28 · HEALTHF0727Severity L · widespread immediate jeopardy
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 · 2026-05-15 · complaint2026-03-28 · HEALTHF0760Severity G · isolated actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2026-04-23 · complaint2026-03-28 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-23 · complaint2026-03-28 · HEALTHF0835Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Correction field: Deficient, Provider has date of correction · 2026-04-23 · complaint2025-05-21 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · 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 · 2025-06-122025-05-21 · 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 · 2025-06-122025-05-21 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-05-292025-05-21 · HEALTHF0814Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-132025-05-21 · FIREK0211Severity F · widespread; 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 · 2025-07-162025-05-21 · 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 · 2025-06-092025-05-21 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-06-242025-05-21 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-05-21 · FIREK0521Severity E · pattern; 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 · 2025-07-072025-05-21 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-06-092024-11-18 · HEALTHF0814Severity C · widespread; potential for minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2024-11-21 · complaint03 / 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 |
|---|---|---|---|
| 2026-03-28 | Payment Denial | $0 | 15 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BRANDMAN, JOSEPHIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST40% · since 10/22/2021
- REBEL, IGORIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST20% · since 10/22/2021
- BRANDMAN, JOSEPHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/22/2021
- REBEL, IGORIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/22/2021
- TOPPER, AARONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/22/2021
- BRANDMAN, JOSEPHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/22/2021
- TOPPER, AARONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/22/2021
- BRANDMAN, JOSEPHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/22/2021
- REBEL, IGORIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/22/2021
- RHODE, ROSALINDAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2021
- TOPPER, AARONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/22/2021
- WEBER, LISAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2021
- BRANDMAN, JOSEPHIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/22/2021
- REBEL, IGORIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/22/2021
- RHODE, ROSALINDAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2021
- TOPPER, AARONIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/22/2021
- WEBER, LISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2021
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 hours3.60per resident day
RN hours0.29per resident day
Weekend nurse hours2.94per resident day
Staff turnover37.5%CMS reported field
06 / LOCAL RECORDS
Open the Fond Du Lac ledger →Other published facilities nearby
Avina Of Fond Du Lac50 beds · CMS overall 2/562 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