Avina on Division

Nursing Home · Fond du Lac, WI

CMS overall rating 1/5 For profit - Limited Liability company

CMS certification number525522

Contact & location

517 E Division St
Fond du Lac, WI 54935
Fond Du Lac County
Phone
(920) 921-6800
ZIP code
54935 – all care providers

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Facility details

Certified beds
50
Residents per day
34.5 (69% occupied)
Ownership
For profit - Limited Liability company
Legal name
Manor of Fond Du Lac LLC
Chain
Avina Healthcare (9 facilities, avg 2.2★)
Medicare certified since
August 24, 1993
Participates in
Medicare and Medicaid

CMS star ratings

Overall★★★★★ 1/5
State avg 3.0
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 1/5
State avg 3.6
Quality measures★★★★★ 3/5
State avg 3.0
Long-stay quality★★★★★ 3/5
Short-stay qualityNot rated

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.60 (state 4.21 · U.S. 3.86)
Registered nurses (RN)
0.29 (state 0.99 · U.S. 0.69)
Licensed practical nurses
1.06 (state 0.64 · U.S. 0.86)
Nurse aides
2.25 (state 2.58 · U.S. 2.32)
Weekend total
2.94 (state 3.77 · U.S. 3.42)
Nursing staff turnover
37.5 (state 46.9 · U.S. 45.8)%
RN turnover
—
Administrators who left
0 in the last year

Inspections

Last standard inspection
May 21, 2025
Health deficiencies (last cycle)
16.0 (state 9.5 · U.S. 9.3)
From complaints
11
Citations on record (3 years)
42 health · 29 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-04-30 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-05-15
2026-04-30 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.
F0584 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-15
2026-04-30 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-15
2026-04-30 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F0694 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-15
2026-03-28 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.
F0727 · Nursing and Physician Services Deficiencies · complaint inspection		 L
Immediate jeopardy to resident health or safety		 Corrected 2026-05-15
2026-03-28 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-04-23
2026-03-28 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-04-23
2026-03-28 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F0725 · Nursing and Physician Services Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-04-23
2026-03-28 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-04-23
2026-03-28 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F0835 · Administration Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-04-23
2026-03-28 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-23
2025-05-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-05-29
2025-05-21 Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-06-12
2025-05-21 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-06-13
2025-05-21 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-06-12
2025-05-21 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-06-12
2024-11-18 Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies · complaint inspection		 C
No actual harm, potential for minimal harm		 Corrected 2024-11-21
2024-03-27 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.
F0801 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-04-19
2024-03-27 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-04-17
2024-03-27 PASARR screening for Mental disorders or Intellectual Disabilities
F0645 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-16
2024-03-27 Give the resident's representative the ability to exercise the resident's rights.
F0551 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-16
2024-03-27 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-03-27
2024-03-27 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-03-27
2024-03-27 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-16
2024-03-27 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-03-27
2024-03-27 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F0806 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-17
2024-03-27 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-17
2024-03-27 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-20
2024-03-27 Post nurse staffing information every day.
F0732 · Nursing and Physician Services Deficiencies		 C
No actual harm, potential for minimal harm		 Corrected 2024-04-18
2023-03-07 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.
F0727 · Nursing and Physician Services Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F0623 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Give the resident's representative the ability to exercise the resident's rights.
F0551 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F0582 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 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.
F0625 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 PASARR screening for Mental disorders or Intellectual Disabilities
F0645 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Provide activities to meet all resident's needs.
F0679 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Provide care or services that was trauma informed and/or culturally competent.
F0699 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F0740 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07
2023-03-07 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-07

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years.

DateTypeAmount
2026-03-28Payment Denial15 days payment denial

Ownership & management

NameRoleSince
Brandman, Joseph (individual)5%+ Direct Ownership Interest · 40%
Rebel, Igor (individual)5%+ Direct Ownership Interest · 20%
Brandman, Joseph (individual)Administrator · NOT APPLICABLE
Rebel, Igor (individual)Administrator · NOT APPLICABLE
Rhode, Rosalinda (individual)Administrator · NOT APPLICABLE
Topper, Aaron (individual)Administrator · NOT APPLICABLE
Weber, Lisa (individual)Administrator · NOT APPLICABLE
Brandman, Joseph (individual)Corporate Officer · NOT APPLICABLE
Topper, Aaron (individual)Corporate Officer · NOT APPLICABLE
Brandman, Joseph (individual)Managing Control - Governing Body · NOT APPLICABLE
Rebel, Igor (individual)Managing Control - Governing Body · NOT APPLICABLE
Topper, Aaron (individual)Managing Control - Governing Body · NOT APPLICABLE
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

Frequently asked questions

What is the rating of Avina on Division?

Avina on Division has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.0-star average in Wisconsin.

How many beds does Avina on Division have?

It has 50 certified beds and cares for about 35 residents per day.

Has Avina on Division been fined?

Yes. CMS lists 1 penalty in the last three years.

Who owns Avina on Division?

It is part of Avina Healthcare and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Avina on Division?

(920) 921-6800. The facility is located at 517 E Division St, Fond du Lac, WI 54935.

Other nursing homes in Fond du Lac

Compare all nursing homes in Fond du Lac, WI →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.