Avina on Division: Immediate Jeopardy RN Shortage - WI
Inspectors who arrived at Avina on Division on March 28 found that the facility had been running this way since March 14. Fourteen days. The finding was immediate jeopardy, the most serious classification federal inspectors can assign, meaning the deficiency created a likelihood of serious harm to residents. The inspection report listed the number of residents affected as "many."
The facility's own interim Director of Nursing laid out the situation plainly when inspectors interviewed her. Certified medication aides, she said, were only permitted to give as-needed pain medication after a nurse had completed a pain evaluation first. Licensed practical nurses, she said, had all been educated that nurses were responsible for completing pain assessments. When inspectors asked who was handling admission assessments for newly arriving or returning residents, she said LPNs were completing most of them, because 99 percent of admissions happen on the evening shift. Her own review of those assessments, she said, would happen on her next scheduled day of work.
That last detail matters. Admission assessments are among the most consequential documents in a nursing home. They establish a resident's baseline, flag existing wounds and infections, identify medications and allergies, and set the foundation for every care decision that follows. At Avina on Division, those assessments were being completed by LPNs on evening shifts, with no RN reviewing them until whenever the interim director happened to be next scheduled in.
An LPN is a licensed professional. That is not the question. The question is what happens to the clinical decisions that require an RN's training and licensure when no RN is available. Pain assessments that need evaluation before medication can be given. IV lines that need competency-verified nursing oversight. Pressure injuries that need to be reassessed and staged. Changes in a resident's condition that need to be recognized and reported up the chain. These are not administrative tasks. They are the core of what a nursing home is supposed to provide.
The facility's own action plan, still being implemented when inspectors left on March 28, listed exactly what had been missing and what they were scrambling to put in place. They needed to hire a full-time interim director of nursing. They needed to bring in an agency RN to cover Saturdays and Sundays, the days when RN coverage had apparently been most at risk. They needed to go back and reassess every resident who had an IV line, every resident with a pressure injury, every resident admitted since March 14, and every resident who had shown a documented change in condition since March 14.
That last category is worth sitting with. The facility, in its own corrective plan, acknowledged it needed to go back and look again at every resident whose condition had changed during those two weeks. That is not a precautionary measure. That is a facility acknowledging that the clinical oversight those residents should have received may not have happened.
The immediate jeopardy designation was removed on March 28, the same day inspectors completed their visit. But the inspection report makes clear that the underlying problem had not been fully corrected by the time they left. The deficiency remained at what CMS classifies as scope and severity level F, meaning the potential for more than minimal harm was widespread across the resident population, and the facility was still in the process of implementing its corrective measures rather than having completed them.
The gap between removing an immediate jeopardy finding and actually fixing the conditions that caused it is a distinction that matters. Immediate jeopardy is removed when a facility presents an acceptable plan and takes sufficient immediate steps to eliminate the likelihood of serious harm. It does not mean the harm that may have already occurred has been addressed, and it does not mean the facility has returned to full compliance. At Avina on Division on March 28, the agency RN to cover weekends was being arranged. The reassessments of residents with IVs and pressure injuries were being scheduled. The staff education on recognizing and reporting changes in condition was being provided. All of it was underway. None of it was done.
The inspection was triggered by a complaint, not a routine survey. Someone contacted regulators about what was happening inside this facility. The report does not say who filed the complaint or what specifically prompted it. What it documents is that when inspectors arrived, they found a facility that had been without required RN staffing for two weeks, without a full-time RN serving as Director of Nursing, and without a clear system for ensuring that the clinical oversight registered nurses are supposed to provide was actually reaching residents.
The interim director's comment about reviewing LPN-completed admission assessments on her next scheduled day of work captures something important about how a staffing failure of this kind propagates through a building. It is not one missed assessment. It is a system operating on the assumption that someone will catch up later, that the review will happen eventually, that the gap between what should occur and what is occurring will be closed before anything goes wrong. Sometimes that assumption holds. The inspection record at Avina on Division, for at least a portion of those fourteen days, suggests it did not.
Residents with IV lines require nursing oversight that carries specific clinical risk if not properly monitored. Residents with pressure injuries, the wounds that develop when someone cannot reposition themselves and staff do not do it for them, can deteriorate rapidly without consistent, skilled assessment. New admissions arrive at their most vulnerable, their medical histories not yet fully known to staff, their conditions not yet stabilized. All of these residents were at Avina on Division between March 14 and March 28, and all of them, according to the facility's own corrective plan, needed to be reassessed after the fact.
The facility did not dispute the finding. The plan of correction was submitted. The immediate jeopardy was lifted. The work of going back through two weeks of residents, two weeks of condition changes, two weeks of admissions, was still happening when inspectors walked out the door.
What that reassessment found, and what it may have been too late to change, is not recorded in this inspection report.
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 immediate jeopardy violations during a health inspection on March 28, 2026.
Inspectors who arrived at Avina on Division on March 28 found that the facility had been running this way since March 14.
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.