Federal inspection record · CMS data as of October 1, 2026
Avina of Pewaukee
N26 W23977 Watertown Rd., Waukesha, WI · (262) 523-0933
- Certified beds
- 120
- Residents per day
- 84
- Ownership
- For-Profit
- Chain
- Avina Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 28, 1998
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Avina of Pewaukee carries 115.75 inspection points. That is fewer than 25% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
56 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care21E
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide activities to meet all resident's needs.
- E
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
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
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
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.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Resident Rights7E
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- E
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
Honor the resident's right to organize and participate in resident/family groups in the facility.
- E
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.
- D
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.
- E
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
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.
Pharmacy Service7E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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
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.
Freedom from Abuse, Neglect, and Exploitation7E
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Respond appropriately to all alleged violations.
Nutrition and Dietary5F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Dispose of garbage and refuse properly.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Resident Assessment and Care Planning3D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control2F
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
Environmental1E
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Nursing and Physician Services1E
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Administration1D
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspection history
2026-08-07
14 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2025-06-09
15 health deficiencies · 12 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-03-04
27 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 22 min of nursing staff time a day, 32 min of it from a registered nurse.
This home
3 h 22 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 45% of nursing staff and 25% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$95,791 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2023-12-26 | Fine | $95,791 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine4 pts better | 100.0% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.8 pts better | 97.4% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.4 pts worse | 4.7% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.1 pts better | 3.9% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts worse | 6.7% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.5 pts better | 9.3% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.3 pts better | 10.6% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened8.9 pts better | 8.1% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.9 pts better | 8.9% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.9 pts better | 0.0% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.1 pts better | 1.6% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.3 pts worse | 24.9% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.2 pts better | 4.7% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine6.9 pts better | 93.8% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.7 pts worse | 23.3% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.1 pts worse | 1.3% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine5.8 pts worse | 76.4% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.5 pts worse | 25.0% | 22.5% | 23.4% |
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Who owns and runs it
4 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Rebel, Igor | 5% Or Greater Direct Ownership Interest · Individual | 20% | 13 facilities |
| Topper, Cecilia | 5% Or Greater Direct Ownership Interest · Individual | 16% | 3 facilities |
| Brandman, Joseph | Operational/Managerial Control · Individual | 0% | 16 facilities |
| Topper, Aaron | Operational/Managerial Control · Individual | 0% | 18 facilities |
·
Fire safety
27 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- F
Install a fire alarm system that can be heard throughout the facility.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- F
Install an approved automatic sprinkler system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Construct fire resistant interior walls.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- C
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous4F
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- C
Have simulated fire drills held at unexpected times.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Egress4F
- F
Have properly located and lighted "Exit" signs.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Emergency Preparedness3F
- F
Include a process for Emergency Preparedness collaboration.
- F
Develop Emergency Preparedness policies and procedures.
- F
Conduct risk assessment and an All-Hazards approach.
Gas, Vacuum, and Electrical Systems2F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
Services2E
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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Other homes nearby
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Lindengrove Waukesha
Waukesha, WI
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 1 min
- Fines
- $204,321
-
Complete Care at Kensington
Waukesha, WI · Complete Care
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 45 min
- Fines
- $66,632
-
Aria of Waukesha
Waukesha, WI · Abuse icon
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 34 min
- Fines
- $81,965