Avina on Division: Unlicensed IV Medication Failures - WI
When inspectors arrived at the Fond du Lac nursing home in late March, they found that LPN1 had been administering IV medications through PICC lines since she was first hired at the facility. She told inspectors on March 27 that the training she relied on was something she had picked up in school to become an LPN, not anything the facility had ever provided. Her employee file confirmed it: no documented IV training of any kind.
She also told inspectors that at times she was one of only two people in the building capable of administering medications to residents with PICC lines. The other was a CMA/MT.
The medication at the center of the inspection was Ertapenem, a broad-spectrum carbapenem antibiotic used for severe bacterial infections. A resident identified in the report as R5, admitted with diagnoses including osteomyelitis of the vertebra and diabetes, had a physician's order for one gram of the drug intravenously at bedtime. The medication administration record for March 2026 showed LPN1 administered it on March 25. The facility's Assistant Director of Nursing, also an LPN, administered it on March 26. Another LPN gave it on March 27.
The ADON told inspectors on March 26 that LPN1 was not certified to administer medications via IV or PICC line. She said this the day after LPN1 had done exactly that.
The facility's Director of Nursing, identified in the report as the FDON and described as the only registered nurse employed by the facility, was interviewed on the evening of March 28. She told inspectors she was responsible for the oversight and supervision of all licensed nursing staff. When asked whether LPN1 and LPN2 had received the additional training or certification needed to administer IV medications, the FDON said she had observed both nurses administer IV medications and had no concerns.
The IV violations were one part of what inspectors found. The other involved who was conducting admission assessments on newly arriving residents, and the answer was: not a registered nurse.
Admission assessments are supposed to be completed by an RN. At Avina on Division, LPNs had been doing them instead. The FDON explained why: 99 percent of admissions arrive on the evening shift, and she was the only RN at the facility. She told inspectors she would review whatever the LPNs completed on her next scheduled workday.
When inspectors asked her directly whether LPNs were permitted to complete admission assessments under their scope of practice, she said "probably not."
The residents whose assessments were completed without RN involvement were not low-acuity patients. R6, admitted March 24, came in with sepsis, diabetes, congestive heart failure, and end-stage renal disease. R8, admitted March 17, had chronic congestive heart failure. R9, admitted the same day, had COPD and traumatic ischemia of muscle. In each case, the admission data collection notes and baseline care plan tools were completed and signed by LPNs. There was no evidence an RN completed any of their assessments.
LPN6 told inspectors during an interview on the evening of March 28 that LPNs had been completing all admission assessments for approximately seven or eight years.
Seven or eight years.
LPN5, interviewed shortly after, said that prior to being educated on the issue that same day during the inspection, she had believed LPNs were permitted to complete admission assessments.
The ADON put the timeline in slightly different terms. She told inspectors that since the facility had been without a Director of Nursing, who had been the facility's only employed RN before the current FDON, LPNs had been completing all initial nursing assessments for newly admitted residents. That framing suggested a gap in RN leadership that preceded the current director. LPN6's account of seven or eight years suggested the practice had become simply how things were done, regardless of who held the title.
The FDON, on her last interview of the inspection, said she had always planned to review the LPN-completed assessments when she returned to work. For residents arriving with sepsis or end-stage renal disease in the hours after she left for the day, that review would come later, if it came at all.
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.
Her employee file confirmed it: no documented IV training of any kind.
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.