Avina of Fond du Lac

In the surveyor’s words

From the most serious findings on record at Avina of Fond du Lac, in the surveyor’s own words.

• Immediate jeopardy, isolatedF660Oct 19, 2023

  Based on resident and staff interviews and record review, the facility did not ensure a safe discharge for 1 of 3 residents R1 (Resident) reviewed for discharge. Prior to admission R1 lived in a motorhome in a campground, which is not wheelchair or walker accessible and has a [NAME] bed. On 10/13/23, R1 was taken, by transport van, to his motorhome, with 2 staff accompanying. R1 was unable to navigate the three steps into the motorhome with staff assistance. R1 started to fall backwards, and staff assisted R1 into his wheelchair. Staff observations of the interior of R1's motorhome were it was uninhabitable, with multiple jugs of urine, no bathroom facilities, no running water, no food, and full of junk. […]

• No harm, potential for more than minimal, widespreadF727Jul 17, 2025

  Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 43 residents residing in the facility.The facility did not have an RN on duty 8 consecutive hours per day 7 days per week on 1/4/25, 1/5/25, and 2/16/25. From 7/15/25 through 7/17/25, Surveyor reviewed the nurse staffing schedules for sampled days based on the facility's Payroll Based Journal (PBJ). The facility triggered for low weekend staffing for Fiscal Year (FY) Quarter 2 (January 2025 through March 2025). […]

• No harm, potential for more than minimal, widespreadF727Jun 5, 2024

  Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 46 residents residing in the facility. The facility did not have an RN on duty for 8 consecutive hours per day 7 days per week on 24 of 26 days reviewed. Findings include: Between 6/3/24 and 6/5/24, Surveyor reviewed the nurse staffing schedules for sampled days based on the facility's Payroll Based Journal (PBJ). The facility triggered for no RN hours on 25 weekend days between October 2023 and December 2023. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2024

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 46 of 46 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates. Findings include: On [DATE] at 8:39 AM, Dietary Manager (DM)-C stated the facility follows the Wisconsin Food Code as their standard of practice. Open/Unlabeled/Undated/Expired Food: The Wisconsin Food Code 2020 documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety (TCS) Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S ,d+[DATE].12, and except as specified in (E), (F), and (H) of this… […]

• No harm, potential for more than minimal, widespreadF727Mar 15, 2023

  Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day seven days a week on 6 of 42 days reviewed. The facility did not have an RN on duty for at least eight consecutive hours on 2/4/23, 2/5/23, 2/12/23, 2/26/23, 3/4/23 and 3/5/23. Findings include: On 3/15/23, Surveyor reviewed the facility's nursing schedules for February 2023 and the first 14 days of March 2023. On the following weekend dates, the facility did not have an RN scheduled to work at least eight consecutive hours within a 24-hour period: 2/4/23, 2/5/23, 2/12/23, 2/26/23, 3/4/23 and 3/5/23. […]