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C
Below Standard

Avina on Division

517 E DIVISION ST · FOND DU LAC, WI 54935

9209216800 · For profit - Limited Liability company

50 beds32.5 residents69 staff
CMS Five-Star Ratings
Overall
★★★★★
Staffing
★★★★★
Quality
★★★★★
Inspections
★★★★★
Staffing Grades
B
Good
Total Staff
C
Below Standard
RN Staff
C
Below Standard
Overall
✓CMS Benchmark(≥ 3.48 HPRD)
✗RN Recommendation(≥ 0.75 HPRD)
✗Research Standard(≥ 4.10 HPRD)
📋

What This Means in Plain English

Avina on Division receives an overall staffing grade of C (Below Standard). With 3.7637 total nurse hours per resident per day, this facility meets the CMS staffing benchmark and has RN staffing of 0.4178 HPRD, below the recommended 0.75. It is 0.13 HPRD below the national average.

Weekend staffing decreases noticeably — dropping 19.77% compared to weekdays. The facility has low agency staff usage (0.53% of hours), suggesting a mostly permanent workforce.

Staffing levels have been trending upward over recent quarters.

🔍 Areas of Concern (2)

⚠️Had 2 days with zero registered nurse hours this quarter. While below the 4-day threshold for an auto 1-star rating, any zero-RN day is a concern.
⚠️RN staffing (0.4178 HPRD) is below the research-recommended minimum of 0.75 HPRD. This means less clinical oversight per resident.

✨ Strengths (2)

✅Meets the CMS staffing benchmark (≥ 3.48 HPRD)
✅Low agency staff usage (0.53%) — mostly permanent, familiar staff
Total Nurse HPRD
3.7637hrs/resident/day▼ 0.13
CMS benchmark: 3.48
RN HPRD
0.4178hrs/resident/day▼ 0.27
Recommended: 0.75
Weekend Drop-off
19.77%
3.9864 weekday → 3.1982 weekend
Agency Staff
0.53%
0% of RN hours from contractors
Days with Zero RN
2days this quarter
4+ days = auto 1-star
CNA HPRD
2.0324hrs/resident/day
Direct care aides
LPN HPRD
1.1513hrs/resident/day
Licensed practical nurses
Consistency
0.5011std dev
Lower = more predictable

HPRD Over Time

Total nurse staffing hours per resident per day, by quarter

Total HPRD (shaded area)RN HPRDCMS Benchmark (3.48) — staffing standardResearch Standard (4.10) — recommended level

How Does This Facility Compare?

Compared to county, state, and national averages for total nurse HPRD

vs. Fond Du Lac County Average-0.10 HPRD
3.86
03.76 HPRD
vs. Wisconsin State Average-0.43 HPRD
4.20
03.76 HPRD
vs. National Average-0.13 HPRD
3.90
03.76 HPRD
■ Colored bar = this facility · | Black line = average · Based on 2025Q3 data

Nearby Facilities

Compare with other nursing homes in the area

FacilityDistanceGradeTotal HPRDRN HPRDCMS Rating
Avina on Division ★
FOND DU LAC · This facility
—
C
3.76370.4178★★★☆☆
HARBOR HAVEN HEALTH & REHABILITATION
FOND DU LAC
0.2 mi
A
4.48791.1214★★★★★
EDENBROOK OF FOND DU LAC
FOND DU LAC
0.6 mi
B
3.60750.9374★★★☆☆
Avina of Fond du Lac
FOND DU LAC
1 mi
B
3.90210.5695★★☆☆☆
EDENBROOK OF OSHKOSH
OSHKOSH
18.7 mi
C
3.28780.7201★★☆☆☆
Complete Care at Christian Home LLC
Waupun
19.4 mi
A+
5.04761.3355★★★☆☆

Inspection History & Penalties

Health inspection results from state surveys — most recent first

4
Inspections
35
Total Deficiencies
$0
Fines Assessed
May 21, 2025Health
5 deficiencies cited
▼
Nov 18, 2024Health
1 deficiency cited
▼
Mar 27, 2024Health
12 deficiencies cited
▼
Mar 7, 2023Health
17 deficiencies cited
▼
CMS Severity Scale
A–C: No Harm / PotentialD–F: No Harm but ConcernG–H: Actual HarmI–L: Immediate Jeopardy

Source: CMS Staffing & Quality Data — 2025Q3 · data.cms.gov

Staffing grades are based on CMS-published thresholds and research recommendations. CMS is not affiliated with and does not endorse this website.