Avina on Division: Dignity Violations in Toileting Care - WI
The woman, identified in inspection records only as Resident 2, requires two staff members and a lift to use the toilet safely. According to records from a complaint inspection completed March 28, 2026, sometimes staff would bring her a bedpan. Other times, they would slide an incontinence pad beneath her and leave her to go in her bed.
Inspectors asked her how that made her feel.
"Uncomfortable and embarrassing," she said.
She knew there was another way. A sit-to-stand lift could transfer her out of bed and get her to the toilet. She had used it recently, she told inspectors during an interview the evening of March 25. It worked. "If staff would use the sit-to-stand lift to get her up," she said, "then maybe she could use the toilet."
The inspection record notes a discrepancy at the center of this failure. The information recorded on her Kardex, the quick-reference care document staff use at the bedside, did not match what her formal care plan actually required. Her care plan called for two-staff assist with a bedpan for toileting. Her Kardex said something different. When the documents don't match, staff work off whatever's in front of them. What was in front of them, apparently, was permission to improvise.
The inconsistency was not a paperwork technicality. It was the mechanism by which a woman who could feel her own body's signals ended up lying on an absorbent pad, waiting.
The situation had escalated months before inspectors arrived. On November 28, 2025, police responded to a call from Resident 2 at the facility. Licensed Practical Nurse 1, who was working that night, confirmed the police visit during an interview the following March. She told inspectors she had explained to police at the time that there had been a miscommunication and that Resident 2 did not get the care she needed.
That phrase, "did not get the care she needed," covered a lot of ground.
The nurse said something else during that interview, something that cut past the specifics of one resident and one night. She said she felt like the residents needed more attention than staff could provide.
She did not elaborate. The inspection record does not pursue it. But the statement sits there in the report, offered by a nurse who had just confirmed that a resident called the police because she couldn't get help using the bathroom, and who then described a facility where, in her assessment, there were not enough people to go around.
Avina on Division is a nursing facility at 517 East Division Street in Fond du Lac. The inspection was triggered by a complaint, not a routine review. Inspectors classified the harm level as minimal, with few residents affected.
Resident 2 might have a different word for it than minimal. She is a woman who knows her own body, who can tell when she needs to go, who found a solution herself after someone finally used the sit-to-stand lift with her and it worked. She brought that information to the inspectors. She told them what she needed. She had, presumably, told staff the same thing.
The pad went under her anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avina On Division from 2026-03-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
Avina on Division in Fond du Lac, WI was cited for violations during a health inspection on March 28, 2026.
The woman, identified in inspection records only as Resident 2, requires two staff members and a lift to use the toilet safely.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.