Map showing the location of Avina on Division in FOND DU LAC, Wisconsin
517 E DIVISION ST, FOND DU LAC, WI, 54935

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinAbove only 42% of peers321 rated homes · average 3.0★
  • Fond Du Lac CountyAbove only 33% of peers7 rated homes · average 3.0★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs WI avg
  • StaffingCan add or remove a star3★−0.7 vs WI avg
  • Quality measuresCan add or remove a star4★+0.9 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 44% of peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 19% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 58% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.76hrsAbove only 34% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.42hrsAbove only 3% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better26%Top 6%WI avg48%RN turnover50%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 42% of peersWI avg$41,875Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
35citations
4inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
May 21, 2025most recent

Citations by monthMar 2023 – May 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

May 21, 20255 citationsCycle 1worst F · no actual harm
  1. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Jun 12, 2025
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 13, 2025
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jun 12, 2025
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jun 12, 2025
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 29, 2025
Nov 18, 20241 citationCycle 2worst C · minimal potential harm
  1. F814Dispose of garbage and refuse properly.Nutrition and DietaryC · widespreadCorrected Nov 21, 2024
Mar 27, 202412 citationsCycle 2worst F · no actual harm
  1. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 27, 2024
  2. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Apr 18, 2024
  3. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Apr 19, 2024
  4. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Apr 17, 2024
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 17, 2024
  6. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 20, 2024
  7. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Apr 17, 2024
  8. F551Give the resident's representative the ability to exercise the resident's rights.Resident RightsD · isolatedCorrected Apr 16, 2024
  9. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 27, 2024
  10. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 27, 2024
  11. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Apr 16, 2024
  12. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 16, 2024
Mar 7, 202317 citationsCycle 3worst F · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Apr 7, 2023
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 7, 2023
  3. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Apr 7, 2023
  4. F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected Apr 7, 2023
  5. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Apr 7, 2023
  6. F551Give the resident's representative the ability to exercise the resident's rights.Resident RightsD · isolatedCorrected Apr 7, 2023
  7. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Apr 7, 2023
  8. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Apr 7, 2023
  9. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Apr 7, 2023
  10. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Apr 7, 2023
  11. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Apr 7, 2023
  12. F727Have 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 ServicesF · widespreadCorrected Apr 7, 2023
  13. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Apr 7, 2023
  14. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 7, 2023
  15. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 7, 2023
  16. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Apr 7, 2023
  17. 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.Resident RightsD · isolatedCorrected Apr 7, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.76hrsAbove only 34% of peers−0.43 vs WI avg
  • Registered nursesRN hours only0.42hrsAbove only 3% of peers−0.54 vs WI avg
  • Licensed practical nursesLPN hours1.15hrs
  • Nurse aidesCNA hours2.19hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.19hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better26%Top 6%WI avg 48%
  • RN turnoverRegistered nurses only50%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy50 certified beds · ~33 residents a day65%Above only 30% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $41,875WI avg in fines
Above only 42% of peersFewer fines than 42% of rated homes in Wisconsin

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Wisconsin facilities average 1.2 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Avina Healthcare8 facilities in the chain2.6★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Joseph Brandman
  • Igor Rebel
  • Aaron Topper
Operational or managerial control
  • Joseph Brandman
  • Igor Rebel
  • Rosalinda Rhode
  • Aaron Topper
  • Lisa Weber
Corporate officers
  • Joseph Brandman
  • Aaron Topper

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525522 · 517 E DIVISION ST, FOND DU LAC, WI, 54935.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Fond Du Lac County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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