Federal inspection record · CMS data as of October 1, 2026
Avina of Fond du Lac
115 E Arndt St, Fond du Lac, WI · (920) 923-7040
- Certified beds
- 50
- Residents per day
- 44
- Ownership
- For-Profit
- Chain
- Avina Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 1, 1976
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Avina of Fond du Lac carries 99.5 inspection points. That is fewer than 30% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
32 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
J
Plan the resident's discharge to meet the resident's goals and needs.
Everything else, by area of care
Quality of Life and Care8D
- D
Provide appropriate foot care.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights6E
- E
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.
- D
Give the resident's representative the ability to exercise the resident's rights.
- D
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.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Pharmacy Service5E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Freedom from Abuse, Neglect, and Exploitation5D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Nutrition and Dietary3F
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services2F
- F
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.
- F
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.
Resident Assessment and Care Planning1D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Infection Control1D
- D
Provide and implement an infection prevention and control program.
Inspection history
2025-07-17
18 health deficiencies · 11 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2024-06-05
6 health deficiencies · 16 fire-safety deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2023-05-17
8 health deficiencies · 6 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 7 min of nursing staff time a day, 28 min of it from a registered nurse.
This home
4 h 7 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 47% of nursing staff and 71% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$7,446 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2023-10-19 | Fine | $7,446 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.7 pts better | 98.7% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 97.7% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury3.2 pts worse | 6.5% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms17.4 pts worse | 23.4% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.9 pts worse | 5.8% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication13 pts worse | 29.8% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.5 pts better | 13.4% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1 pts better | 16.0% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased8.1 pts better | 7.7% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.1 pts better | 0.8% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.4 pts better | 1.3% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.5 pts worse | 29.1% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers5.2 pts worse | 10.1% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.3 pts better | 90.2% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.2 pts better | 15.4% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine4.8 pts better | 87.0% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3 pts worse | 25.5% | 22.5% | 23.4% |
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Who owns and runs it
9 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Rebel, Igor | 5% Or Greater Direct Ownership Interest · Individual | 20% | 13 facilities |
| Rebel, Igor | Adp Of The SNF · Individual | 0% | 13 facilities |
| Rhode, Rosalinda | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Rhode, Rosalinda | Adp Of The SNF · Individual | 0% | 2 facilities |
| Topper, Aaron | Direct Ownership Interest · Individual | 0% | 18 facilities |
| Topper, Aaron | Managing Control - Governing Body · Individual | 0% | 18 facilities |
| Topper, Aaron | Adp Of The SNF · Individual | 0% | 18 facilities |
| Weber, Lisa | Operational/Managerial Control · Individual | 0% | 8 facilities |
| Weber, Lisa | Adp Of The SNF · Individual | 0% | 8 facilities |
·
Fire safety
33 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10E
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Egress7F
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F
Have properly located and lighted "Exit" signs.
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- D
Have exits that are accessible at all times.
- D
Install emergency lighting that can last at least 1 1/2 hours.
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Gas, Vacuum, and Electrical Systems5F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have power receptacles that are properly grounded.
- D
Meet requirements for the use of electrical equipment.
- D
Have proper medical gas storage and administration areas.
- E
Have proper medical gas storage and administration areas.
Emergency Preparedness4F
- F
Establish emergency prep training and testing.
- F
Develop and maintain an Emergency Preparedness Program (EP).
- F
Address patient/client population and determine types of services needed.
- F
Establish emergency prep training and testing.
Miscellaneous4F
- C
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have restrictions on the use of flammable curtains.
Services3E
- E
Have an externally vented heating system.
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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Other homes nearby
-
Fond du Lac Lutheran Home
Fond du Lac, WI · Illuminus
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 51 min
- Fines
- $9,113
-
St Francis Home
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★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 33 min
- Fines
- $0
-
Avina on Division
Fond du Lac, WI · Avina Healthcare
★★★★★- Worst citation, 3 yrs
- L
- Nursing / resident / day
- 3 h 37 min
- Fines
- $58,210