Avina on Division: Wrong IV Antibiotic Given to Resident - WI
The resident at Avina on Division, a nursing facility at 517 E. Division Street, was in the middle of a weeks-long course of daptomycin for osteomyelitis of the lumbar vertebra and a psoas muscle abscess, a serious infection that had burrowed into the tissue alongside her spine. The antibiotic had been ordered to run from December 18, 2025 through January 14, 2026. On the morning of January 13, with one day left in the treatment course, a licensed practical nurse gave her ertapenem instead, a different antibiotic prescribed for a different resident entirely.
The nurse, identified in inspection records as LPN1, prepared the medication occurrence report herself. She wrote that she had given an IV from another resident to the resident. She noted the nurse practitioner and the resident were informed. No injuries were observed at the time.
A risk management review completed the following day described what had happened in plainer terms: the resident was supposed to receive daptomycin 540 milligrams intravenously and received ertapenem 1 gram instead. The interdisciplinary team met, the advanced practice nurse prescriber was called, and staff were told to monitor the resident for 72 hours. No adverse reactions were noted. No further orders were issued. The case manager was updated. The resident was updated and declined to have family notified.
The review also noted that all nurses received education on the six rights of medication administration.
Except that wasn't what happened.
When inspectors interviewed LPN1 on March 27, 2026, she described the error in straightforward terms. The facility had previously only had one resident receiving IV medications, she said. On that day, a second resident had been added. She didn't check thoroughly enough and grabbed the wrong bag from the refrigerator.
When she realized the mistake, she said the director of nursing had her notify the on-call physician to determine whether there would be a problem.
Then she said something that contradicted the facility's own written account. She had been educated on the five patient rights, she told inspectors, not six. And when asked whether other staff had received the same training after the incident, she said it was just her.
The risk management review said all nurses had been educated. LPN1 said she was the only one.
"It was a stupid mistake and should not have happened," she told inspectors.
The violation was cited at the level of actual harm.
What the inspection record does not resolve is what the difference between daptomycin and ertapenem meant for this particular resident at this particular stage of her treatment. The two drugs are not interchangeable. Daptomycin had been specifically ordered for her infection, a combination of vertebral osteomyelitis and a psoas abscess that had already required weeks of intravenous therapy. Ertapenem is a different class of antibiotic, prescribed for someone else's condition entirely. The facility noted no adverse reaction and no changes during the monitoring period. Whether the substitution affected the final day of her treatment course is not addressed in the inspection report.
The resident chose not to have her family told.
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 resident at Avina on Division, a nursing facility at 517 E.
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.