Avina on Division: Nurse Ignored Chest Pain Call - WI
The incident, documented during a March 28 complaint inspection, was classified as causing actual harm to a resident identified in the report as R2.
R2 was described as fairly independent and assertive enough that she would call the facility directly if staff weren't responding to her. On the day in question, she had just come in from smoking when she told a nurse, identified as LPN1, that her chest had been feeling funny lately and that she might need to go to the hospital. LPN1 was in the middle of a medication pass at the time.
LPN1 told inspectors she looked at R2 and decided the resident was not in dire need. She said R2 "complained about different things and ailments" regularly, that R2 was talking fine, and that nothing seemed different about this particular moment. So she kept working.
"I figured she had a few minutes to get down there," LPN1 told inspectors, referring to the walk to R2's room.
When she finally made it, R2's husband had already placed the 911 call. LPN1 did not conduct an assessment. She did not take vital signs. She did not call the physician or the nurse practitioner.
Inspectors asked LPN1 a direct question: would she have responded differently if this had been any other resident?
She said she would have assessed them.
The Medical Director told inspectors she expected staff to conduct an assessment, obtain vital signs, and report to her or the nurse practitioner any time a resident said they wanted to go to the hospital. She said it was the first time she had heard about the incident involving R2, though she noted the nurse practitioner might be aware.
LPN1 acknowledged that the administrator and director of nursing had spoken with her after the incident and told her an assessment should have been completed.
That conversation happened after the fact. R2 had already been taken out by ambulance.
What the report does not say is what happened to R2 after she left the facility. It does not say whether her chest symptoms indicated something serious, whether she was admitted, or what her condition was when paramedics arrived. The inspection narrative ends where the ambulance ride begins.
What it does say is that a nurse made a judgment call based on her personal read of a resident's credibility, skipped the assessment entirely, and later admitted to inspectors that she would have handled it differently for someone else. The Medical Director, whose standing expectation was that any report of wanting to go to the hospital triggers an assessment and a call to the clinical team, learned about the incident from inspectors.
Shortness of breath and chest discomfort in an older adult can signal a cardiac event, a pulmonary embolism, or other conditions where minutes matter. LPN1 knew R2 was short of breath. She heard her say she might need to go to the hospital. She decided to finish what she was doing first.
R2's husband made a different call.
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 incident, documented during a March 28 complaint inspection, was classified as causing actual harm to a resident identified in the report as R2.
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.