Wisconsin › Waukesha County › Waukesha
Avina of Pewaukee
N26 W23977 Watertown Rd., Waukesha, WI 53188
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Certified for 120 beds, Avina of Pewaukee serves Waukesha in Waukesha County, Wisconsin and has taken Medicare and Medicaid residents since 1998.
CMS gives it 1 of 5 stars overall, below the Wisconsin median of 3; the health inspection rating is 1, staffing 2 and quality measures 2.
Inspectors recorded 55 health deficiencies across the three most recent survey cycles (19, 20, 16 by cycle, most recent first), 2 of them at the actual-harm or immediate-jeopardy level. That is 45.8 per 100 beds, more than the state median of 31.8.
CMS lists 1 penalty in the period covered: fines totalling $96K.
Reported nurse staffing is 3.3 hours per resident per day (0.5 RN), close to the Wisconsin median of 4.0; nursing staff turnover is 43.3%.
Compared with county, state and nation
| Measure | This facility | Waukesha Co. median | Wisconsin median | US average |
|---|---|---|---|---|
| Overall star rating | 1 | 1 | 3 | 3.0 |
| Health citations, 3 cycles | 55 | 37 | 21 | 28.7 |
| Citations per 100 beds | 45.8 | 45.5 | 31.8 | 26.8 |
| Total nurse hours per resident day | 3.3 | 4.1 | 4.0 | 3.9 |
| RN hours per resident day | 0.5 | 0.7 | 0.9 | 0.7 |
| Nursing staff turnover | 43.3% | 55.8% | 46.2% | 45.8% |
| Fines listed | $95,791 | $95,791 | $0 | — |
County and state figures are medians across facilities (17 in the county, 323 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Wisconsin average per facility for the same cycle, as published by CMS. Standard health survey dates: 9 Jun 2025, 4 Mar 2024.
Severity mix: J ×1 G ×1 D ×35 E ×15 F ×3
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 18 Mar 2026 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Complaint investigation | 13 Apr 2026 |
| 18 Mar 2026 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 13 Apr 2026 |
| 18 Mar 2026 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 13 Apr 2026 |
| 18 Mar 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | 13 Apr 2026 |
| 18 Mar 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 13 Apr 2026 |
| 15 Jul 2025 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 14 Aug 2025 |
| 9 Jun 2025 | F0814 | Dispose of garbage and refuse properly. | F | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Complaint investigation | 9 Jul 2025 |
| 9 Jun 2025 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | E | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0679 | Provide activities to meet all resident's needs. | E | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0692 | Provide enough food/fluids to maintain a resident's health. | E | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Complaint investigation | 9 Jul 2025 |
| 9 Jun 2025 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Complaint investigation | 9 Jul 2025 |
| 9 Jun 2025 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D | Complaint investigation | 9 Jul 2025 |
| 9 Jun 2025 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard survey | 9 Jul 2025 |
| 9 Jun 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 9 Jul 2025 |
| 9 Jun 2025 | F0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Complaint investigation | 9 Jul 2025 |
| 9 Jun 2025 | F0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | D | Complaint investigation | 9 Jul 2025 |
| 20 Aug 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 13 Sep 2024 |
| 20 Aug 2024 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 13 Sep 2024 |
| 20 Aug 2024 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint investigation | 13 Sep 2024 |
| 20 Aug 2024 | F0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Complaint investigation | 13 Sep 2024 |
| 20 Aug 2024 | F0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D | Complaint investigation | 13 Sep 2024 |
| 20 Aug 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint investigation | 13 Sep 2024 |
| 4 Mar 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0880 | Provide and implement an infection prevention and control program. | F | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | E | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard survey | 26 Mar 2024 |
| 4 Mar 2024 | F0800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | D | Standard survey | 26 Mar 2024 |
| 26 Dec 2023 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint investigation | 15 Jan 2024 |
| 26 Dec 2023 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Complaint investigation | 15 Jan 2024 |
| 26 Dec 2023 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 15 Jan 2024 |
| 26 Dec 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 15 Jan 2024 |
| 26 Dec 2023 | F0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D | Complaint investigation | 15 Jan 2024 |
| 26 Dec 2023 | F0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Complaint investigation | 15 Jan 2024 |
| 21 Nov 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 1 Dec 2023 |
| 21 Nov 2023 | F0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D | Complaint investigation | 15 Dec 2023 |
| 1 Dec 2022 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | E | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard survey | 28 Dec 2022 |
| 1 Dec 2022 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 28 Dec 2022 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 26 Dec 2023 | Fine | $95,791 |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Wisconsin average. Turnover: nursing staff 43.3%, RNs 37.5%; 0 administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 5.4% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.9% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.1% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.3% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 6.5% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.6% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 12.8% | 14.4% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, corporation. Legal business name: Ccc Of Pewaukee Llc. Chain: Avina Healthcare (9 facilities).
No organisations are listed in the CMS ownership record for this facility.
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Waukesha County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Masonic Center For Health & Rehab Inc. | Dousman | 50 | 5 | 5 | 5 | 3 | 6.0 | — | 29 Jan 2026 |
| Shorehaven Hlth & Rehab Ctr | Oconomowoc | 88 | 5 | 4 | 5 | 10 | 11.4 | — | 5 Mar 2026 |
| Congregational Home, Inc. | Brookfield | 66 | 4 | 3 | 5 | 21 | 31.8 | — | 31 Jul 2025 |
| Lake Country Health Services | Oconomowoc | 100 | 2 | 2 | 3 | 42 | 42.0 | $121K | 27 Aug 2025 |
| Lindengrove Mukwonago | Mukwonago | 47 | 2 | 3 | 4 | 25 | 53.2 | — | 10 Dec 2025 |
| Menomonee Falls Health Services | Menomonee Falls | 50 | 2 | 2 | 3 | 46 | 92.0 | $214K | 3 Dec 2025 |
| Muskego Health and Rehabilitation Center | Muskego | 49 | 2 | 2 | 3 | 56 | 114.3 | — | 28 Jan 2026 |
| Tudor Oaks Health Center | Muskego | 50 | 2 | 2 | 3 | 37 | 74.0 | $181K | 5 Dec 2025 |
All 17 facilities in Waukesha County
Questions and answers
How many deficiencies has Avina of Pewaukee been cited for?
55 health deficiencies across the three most recent survey cycles, 2 at the actual-harm or immediate-jeopardy level. The Wisconsin median is 21 per facility.
Has Avina of Pewaukee been fined?
Yes. CMS lists fines totalling $96K in the period covered.
How does staffing at Avina of Pewaukee compare?
Reported total nurse staffing is 3.3 hours per resident per day against a Wisconsin median of 4.0 and a national average of 3.9.
Who operates Avina of Pewaukee?
It is part of the Avina Healthcare chain. Ownership type is for-profit, corporation. Individual owners and managers are not listed on this site.
When was Avina of Pewaukee last inspected?
The most recent survey or investigation in the CMS record is dated 18 Mar 2026; the most recent standard health survey was 9 Jun 2025.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.