Starfile / Wisconsin

Avina of Pewaukee

N26 W23977 Watertown Rd., Waukesha, WI 53188 · CCN 525646

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$95,791

Number of fines

1

Number of penalties

1

Payment denials

0

Chain

Chain

AVINA HEALTHCARE

Facilities in chain

8

Chain avg overall

2.80 / 5

Inspection citations (50)1 immediate jeopardy1 actual harm

1. DF0880Provide and implement an infection prevention and control program.2025-07-15 · Health · corrected 2025-08-14

   Potential for more than minimal harm

2. EF0565Honor the resident's right to organize and participate in resident/family groups in the facility.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

3. DF0578Honor 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.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

4. EF0584Honor 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.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

5. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

6. EF0605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

7. EF0679Provide activities to meet all resident's needs.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

8. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

9. DF0688Provide 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.2025-06-09 · Health · corrected 2025-07-09

   Potential for more than minimal harm

10. EF0692Provide enough food/fluids to maintain a resident's health.2025-06-09 · Health · corrected 2025-07-09

    Potential for more than minimal harm

11. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-06-09 · Health · corrected 2025-07-09

    Potential for more than minimal harm

12. EF0761Ensure 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.2025-06-09 · Health · corrected 2025-07-09

    Potential for more than minimal harm

13. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-06-09 · Health · corrected 2025-07-09

    Potential for more than minimal harm

14. FF0814Dispose of garbage and refuse properly.2025-06-09 · Health · corrected 2025-07-09

    Potential for more than minimal harm

15. DF0847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.2025-06-09 · Health · corrected 2025-07-09

    Potential for more than minimal harm

16. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-08-20 · Health · corrected 2024-09-13

    Potential for more than minimal harm

17. DF0610Respond appropriately to all alleged violations.2024-08-20 · Health · corrected 2024-09-13

    Potential for more than minimal harm

18. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-08-20 · Health · corrected 2024-09-13

    Potential for more than minimal harm

19. DF0688Provide 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.2024-08-20 · Health · corrected 2024-09-13

    Potential for more than minimal harm

20. DF0693Ensure 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.2024-08-20 · Health · corrected 2024-09-13

    Potential for more than minimal harm

21. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-08-20 · Health · corrected 2024-09-13

    Potential for more than minimal harm

22. EF0585Honor 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.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

23. EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

24. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

25. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

26. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

27. DF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

28. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

29. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

30. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

31. DF0761Ensure 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.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

32. DF0800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

33. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

34. FF0880Provide and implement an infection prevention and control program.2024-03-04 · Health · corrected 2024-03-26

    Potential for more than minimal harm

35. EF0584Honor 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.2023-12-26 · Health · corrected 2024-01-15

    Potential for more than minimal harm

36. JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-12-26 · Health · corrected 2024-01-15

    Immediate jeopardy

37. DF0610Respond appropriately to all alleged violations.2023-12-26 · Health · corrected 2024-01-15

    Potential for more than minimal harm

38. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-12-26 · Health · corrected 2024-01-15

    Potential for more than minimal harm

39. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2023-12-26 · Health · corrected 2024-01-15

    Potential for more than minimal harm

40. DF0758Implement 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.2023-12-26 · Health · corrected 2024-01-15

    Potential for more than minimal harm

41. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-11-21 · Health · corrected 2023-12-01

    Potential for more than minimal harm

42. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2023-11-21 · Health · corrected 2023-12-15

    Potential for more than minimal harm

43. EF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

44. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

45. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2022-12-01 · Health · corrected 2022-12-28

    Actual harm

46. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

47. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

48. EF0758Implement 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.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

49. DF0761Ensure 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.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

50. DF0880Provide and implement an infection prevention and control program.2022-12-01 · Health · corrected 2022-12-28

    Potential for more than minimal harm

Ownership

Other facilities in Waukesha

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.