Avina On Division
Avina on Division in Fond du Lac, WI — inspection on April 30, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
4/29/26 at 1:30 PM, Surveyor, NHA-A, and Director of Nursing (DON)-B observed the damage below
indicated R5 was upset and stated R5's family member informed staff about the hole and wanted the
acknowledged the damage in R6's room and indicated the outside layer of plaster may have been wet at one point and needed to be repaired. MD-C stated the way the toilet was mounted to the wall may have something to do with the damage. R6 was in the room and stated R6 felt safe using the toilet.
MD-C also acknowledged the damage in R5's room as a hole in the wall below the toilet. MD-C was not aware either of the bathrooms had damage and stated it was possible a plumber had to get in the wall and did not notify MD-C when the repair was done.
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Avina on Division 517 E Division St Fond Du Lac, WI 54935
treatment to promote healing of a pressure injury for 1 resident (R) (R3) of 1 sampled resident.R3 had
(LPN)-D used soiled scissors to cut silver alginate that was applied to R3's pressure injury. In addition, LPN-D opened a 4x4 gauze package, removed the gauze, and sprayed it with wound cleanser. LPN-D placed the wet gauze on the outside of the gauze package that had touched soiled surfaces.Findings include:The facility's Pressure Injury Prevention and Management policy, revised 6/17/25, indicates: .Provide treatment and services to heal the pressure ulcer/injury, prevent infection .evidence-based treatments in accordance with current standards of practice will be provided for all residents.From 4/29/26 to 4/30/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had a diagnosis of pressure-induced deep tissue damage of unspecified site. R3's Minimum Data Set (MDS) assessment, dated 1/28/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3's cognition was intact.R3's medical record contained the following physician's order for a treatment to R3's right lateral lumbar region distal area:~ Cleanse with wound cleanser or normal saline (NS), apply skin prep to the peri-wound followed by silver alginate to the wound base.
Cover with abdominal (ABD) pad dressing and secure with Hypafix tape.
Change daily and as needed (PRN) (start date: 2/6/26).On 4/29/26 at 10:05 AM, Surveyor observed LPN-D set scissors, a 4x4 gauze package, and an ABD package on a personal protective equipment (PPE) cart outside R3's room. LPN-D donned a gown, completed hand hygiene, and donned gloves. LPN-D picked up the scissors, gauze, and ABD dressing and entered R3's room.
LPN-D set the supplies on R3's uncleansed bedside table. LPN-D picked up the scissors, retrieved silver alginate from a drawer, cut the silver alginate, and placed it back in the package. LPN-D put the scissors and silver alginate on the same bedside table. LPN-D removed gauze from the package, put wound cleanser on the the gauze, and set the wet gauze on top of the package which had touched the PPE cart and bedside table. LPN-D removed R3's soiled dressing, cleansed the wound, and applied skin prep to the peri-wound. LPN-D removed gloves, cleansed hands, and donned new gloves. LPN-D placed the silver alginate on the wound bed, put an ABD dressing over the wound, and used Hypafix tape to secure the dressing. LPN-D assisted R3 onto R3's back, removed gloves, and placed the remainder of the silver alginate in its original package and back in the drawer. LPN-D then exited the room. LPN-D removed LPN-D's gown outside the room then put the gown in the garbage in R3's room.
Surveyor interviewed LPN-D who indicated LPN-D acknowledged the concern with contamination from transferring wound supplies from the PPE cart to the bedside table which were then in contact with R3's wound bed.On 4/29/26 at 10:15 AM, Surveyor interviewed Director of Nursing (DON)-B who verified LPN-D should not have put the scissors on the PPE cart and uncleansed bedside table and used the scissors to cut silver alginate that was directly applied to R3's wound bed. DON-B confirmed putting wet gauze used during wound care on the outside of a package that was in contact with the PPE cart and uncleansed bedside table could contaminate the wound.
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Avina on Division 517 E Division St Fond Du Lac, WI 54935
documented monitoring for signs and symptoms of infection of a PICC line in a resident's progress
but did not have a place to document the length. DON-B stated DON-B would provide Surveyor with
length after catheter placement. DON-B verified with Surveyor that R2 did not have an order for a NS flush and verified there should be physician order for flushes before and after an IV infusion.On 4/30/26 at 12:00 PM, DON-B informed Surveyor the measurement for R2's PICC line external catheter was 10 centimeters (cm) without the hub and 14 cm with the hub. DON-B provided documentation from the placement of the IV catheter and exited the room.On 4/30/26 at approximately 12:20 PM, Surveyor reviewed the placement documentation which indicated the external catheter length was 0 cm.
The placement document indicated R2 had a single lumen power midline for continuation of IV antibiotics.On 4/30/26 at 12:26 PM, Surveyor interviewed Registered Nurse (RN)-E who worked at the infusion clinic written on the bottom of the placement documentation provided by DON-B. RN-E stated R2 had a midline catheter, not a PICC line catheter, and a midline catheter external length should be 0 cm. RN-E stated if any external length was present, the midline catheter was likely migrating out.
RN-E indicated the total length of the catheter was 18 cm and a stat lock should hold the catheter in place. RN-E indicated if the midline catheter was migrating out, hash marks that indicated 1 cm would be visible on the catheter. RN-E stated the facility needed a physician order for flushes every 24 hours and before and after an infusion. RN-E indicated flushing assisted with preventing clogging of the site.On 4/30/26 at 12:39 PM, Surveyor observed R2's midline catheter and noted a stat lock against R2's skin holding the catheter in place underneath a transparent dressing.
The catheter line contained the words midline catheter.
Surveyor observed a 2x2 gauze over the insertion site with a transparent dressing that covered the stat lock and gauze.
Surveyor did not observe hash marks, leaking fluid, redness, or swelling underneath the transparent dressing.On 4/30/26 at 2:06 PM, Surveyor informed DON-B that R2 had a midline catheter which would not have any external catheter to measure as indicated on the placement document DON-B provided earlier. DON-B then stated there was 0 cm of external catheter visible and DON-B did not see any hash marks during R2's dressing change on 4/29/26.
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Avina on Division 517 E Division St Fond Du Lac, WI 54935
fixtures are breather valves.
The rooms contain a sink and a toilet. MD-C stated the activity sink is
flush the other unused fixtures. MD-C verified MD-C is the only one who flushes unused fixtures. (Of
bathtub.)On 4/30/26 at 1:43 PM, Surveyor interviewed NHA-A who acknowledged the facility's WMP does not include identification and control measures for high-risk areas such as the unused showers or the capped and unused plumbing fixtures.
Surveyor requested and NHA-A provided the facility's Water System Infection Control Risk Assessment Tool.
After review of a Risk Assessment, dated June 2025, Surveyor verified the facility identified water system components including six shower heads and hoses.
Two showers were observed during the facility tour. No further documentation was provided to verify the unused fixtures were maintained according to the facility's WMP policy.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.