Avina on Division

Nursing Home Fond Du Lac, WI Medicare and Medicaid
3/5
Overall Rating
3/5
Certified Beds
50
Residents
32
Penalties
0

Ratings & Quality

Overall
3/5
Health Inspection
3/5
Staffing
3/5
Quality
4/5

Staffing Details

RN Hours per Resident per Day0.42
Total Nurse Hours per Resident per Day3.76
Number of Certified Beds50
Number of Residents32

Inspection Deficiencies (35)

0558 2025-05-21 D Not Corrected

Reasonably accommodate the needs and preferences of each resident.

Correction date: 2025-06-12

0755 2025-05-21 D Not Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Correction date: 2025-06-12

0812 2025-05-21 F Not Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Correction date: 2025-05-29

0814 2025-05-21 F Not Corrected

Dispose of garbage and refuse properly.

Correction date: 2025-06-12

0880 2025-05-21 E Not Corrected

Provide and implement an infection prevention and control program.

Correction date: 2025-06-13

0814 2024-11-18 C Not Corrected

Dispose of garbage and refuse properly.

Correction date: 2024-11-21

0551 2024-03-27 D Not Corrected

Give the resident's representative the ability to exercise the resident's rights.

Correction date: 2024-04-16

0580 2024-03-27 D Not Corrected

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Correction date: 2024-03-27

0641 2024-03-27 D Not Corrected

Ensure each resident receives an accurate assessment.

Correction date: 2024-03-27

0645 2024-03-27 E Not Corrected

PASARR screening for Mental disorders or Intellectual Disabilities

Correction date: 2024-04-16

0689 2024-03-27 D Not Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Correction date: 2024-04-16

0695 2024-03-27 D Not Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Correction date: 2024-03-27

0732 2024-03-27 C Not Corrected

Post nurse staffing information every day.

Correction date: 2024-04-18

0801 2024-03-27 F Not Corrected

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.

Correction date: 2024-04-19

0806 2024-03-27 D Not Corrected

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Correction date: 2024-04-17

0812 2024-03-27 F Not Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Correction date: 2024-04-17

0842 2024-03-27 D Not Corrected

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Correction date: 2024-04-17

0880 2024-03-27 D Not Corrected

Provide and implement an infection prevention and control program.

Correction date: 2024-04-20

0609 2023-03-07 D Not Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Correction date: 2023-04-07

0622 2023-03-07 D Not Corrected

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Correction date: 2023-04-07

0624 2023-03-07 D Not Corrected

Prepare residents for a safe transfer or discharge from the nursing home.

Correction date: 2023-04-07

0626 2023-03-07 D Not Corrected

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Correction date: 2023-04-07

0551 2023-03-07 D Not Corrected

Give the resident's representative the ability to exercise the resident's rights.

Correction date: 2023-04-07

0582 2023-03-07 D Not Corrected

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Correction date: 2023-04-07

0645 2023-03-07 D Not Corrected

PASARR screening for Mental disorders or Intellectual Disabilities

Correction date: 2023-04-07

0679 2023-03-07 D Not Corrected

Provide activities to meet all resident's needs.

Correction date: 2023-04-07

0689 2023-03-07 E Not Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Correction date: 2023-04-07

0699 2023-03-07 D Not Corrected

Provide care or services that was trauma informed and/or culturally competent.

Correction date: 2023-04-07

0727 2023-03-07 F Not Corrected

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 date: 2023-04-07

0740 2023-03-07 D Not Corrected

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Correction date: 2023-04-07

0758 2023-03-07 D Not Corrected

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.

Correction date: 2023-04-07

0812 2023-03-07 E Not Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Correction date: 2023-04-07

0623 2023-03-07 E Not Corrected

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Correction date: 2023-04-07

0625 2023-03-07 D Not Corrected

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.

Correction date: 2023-04-07

0692 2023-03-07 D Not Corrected

Provide enough food/fluids to maintain a resident's health.

Correction date: 2023-04-07

About Avina on Division

Avina on Division is a medicare and medicaid certified nursing home in Fond Du Lac, Wisconsin. The facility has 50 certified beds and currently houses 32 residents. It has received an overall quality rating of 3 out of 5 stars from CMS. The facility has 35 inspection deficiencies on record. Registered nurse hours are 0.42 per resident per day.