N26 W23977 Watertown Rd., Waukesha, WI 53188 · Waukesha County · (262) 523-0933
120 certified beds, about 89 residents a day · For profit - Corporation · Medicare and Medicaid since 1998
CMS Care Compare ratings, data as of September 1, 2026 · CCN 525646 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 9, 2025, inspectors cited 14 health deficiencies (the Wisconsin average is 9.5, the national average 9.2).
Of 55 health citations since December 2022, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $95,791 in the last three years; the largest was $95,791, and the latest is dated December 26, 2023.
Nurses and nurse aides worked 3.28 hours per resident per day, against 4.21 across Wisconsin and 3.86 nationally. Registered nurses accounted for 0.51 of those hours.
43.3% of nursing staff left within the year CMS measured (Wisconsin average 46.9%).
CMS links it to Avina Healthcare, an affiliated group of 9 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 55 health citations on file.
Inspectors wroteBased upon observation and interview, the facility did not ensure Residents were provided with a clean and comfortable, homelike environment that included the provision of linens.*On 3/17/26 there was a delay in R10 and R3 receiving their showers as there were no towels on the unit. A count of the nurse storage closets on the Lake Park side of the facility revealed very little or no linen/towels in these nurse storage closets. *The walls of R3, R11, R12, R16, R7, R13, room [ROOM NUMBER], R9, R15, & R14 were observed with gouges and/or holes.
Inspectors wroteBased on record reviews and interviews, the facility did not ensure allegations of abuse were immediately reported to the Nursing Home Administrator and/or Grievance Officer. This was affected 1 (R1) of 1 Resident reviewed for alleged abuse.* Staff did not report allegations of abuse regarding Certified Nursing Assistant (CNA)-E to the Nursing Home Administrator (NHA)-A immediately. This allowed for additional potential allegations of abuse to occur to other residents whom CNA-E provided care to for the remainder of the shift. [...]
Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations involving potential abuse were thoroughly investigated for 1 (R1) of 1 reviewed facility reported incidents (FRI).*An allegation of abuse on 10/30/25 by CNA-E involving R1 was not thoroughly investigated. Findings Include:The facility's last reviewed Abuse, Neglect, and Exploitation policy and procedure documents: Policy:.It is the policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:a. [...]
Inspectors wroteBased on observation, interview and record review, the Facility did not ensure that Residents at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries for 1 (R9) of 1 Residents reviewed. R9 is at high risk for pressure injury development and has a history of pressure injuries. R9's air mattress was not functioning during multiple observations on 3/17/26 & 3/18/26.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure fall interventions were implemented to prevent accidents for 1 (R3) of 2 sampled residents. Fall safety intervention of ensuring a reacher available for safety was not observed being implemented during the survey.
Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(R1) of 3 residents in sample. Surveyor observed 3 staff members provide high contact cares to R1 without following enhanced barrier precautions (EBP) as ordered due to R1's foley catheter placement.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure garbage and refuse was disposed of properly. This has the ability to affect all 87 residents who reside at the facility. Garbage and litter was found near the facility's main dumpster area. Evidenced by: The facility policy, Disposal of Garbage and Refuse, dated 2/1/25, states, in part; .7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. On 6/2/25 at 10:21AM, During initial kitchen tour, Surveyor observed facility dumpsters. Surveyor observed multiple used gloves and pieces of garbage outside the dumpsters. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly for 3 of 3 Supplemental (R23, R21, and R28) and 1 of 1 Sampled Resident (R53). Resident council meeting minutes from March, April, and May of 2025 all include concerns regarding staff using ear buds and cell phones while providing cares. During the resident council meeting with surveyors, R23, R21, and R28 indicated concerns regarding staff using ear buds and cell phones while providing cares. R53 indicated a concern with staff using ear buds and cell phones while providing cares. Evidenced by: The facility policy titled, Resident Council Meetings, date implemented 2/1/25, includes, in part: Policy: [...]
Inspectors wroteExample 5: On 6/4/25 at 1:56 PM, R329 approached surveyor and indicated she just moved on to her current unit yesterday and indicated, This place is horrible. Surveyor observed R329's room with her and R329 indicated the following concerns: 1. It's filthy and there's a lot of dirt. 2. Behind the bed: The floor is dirty behind the bed, the plaster is peeling in multiple areas on the entire wall, it looks like there is blood on the wall. (Resident referring to a pinkish/red substance on the wall). 3. Behind the door to the room -- there is an oblong shaped hole in the wall and pushed into the hole is a round metal piece that looks like the remains of a door stopper for where the door handle hits. Of note, when the door was opened, the handle lines up to this area. 4. No shower head in the bathroom. 5. Black marks on shower floor surrounding. 6. Light above sink not working. 7. [...]
Inspectors wroteExample 4 R46 admitted to the facility on [DATE] with diagnoses including anxiety. R46's physician orders, dated 6/5/25, include Lorazepam 0.5 mg every 6 hours as needed . for 6 months. Monitor for s/s (signs and symptoms) of anxiety; update MD/NP (Medical Doctor/Nurse Practitioner) for worsening symptoms. R46's Certified Nursing Assistant (CNA) Kardex (CNA care plan), printed 6/5/25, does not include monitoring or interventions related to R46's anxiety. R46's comprehensive care plan, printed 6/5/25, states in full, for R46's anxiety disorder: Focus: The resident has an active order for anti-anxiety medication(s) use anxiety disorder Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer Anti-anxiety medications as ordered by physician. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident this affected 4 of 23 Residents (R57, R46, R67, and R56) reviewed for activities. Surveyor observed R57, who needs assistance to/from structured leisure activities, not being provided activities. The facility failed to ensure R46's activity care plan is meaningful, personalized, and had measurable goals. R56's Comprehensive Care Plan does not contain an activities care plan. R67's Comprehensive Care Plan does not actually list any Resident specific preferred activities. Evidenced by: The facility policy, Activities, dated 2/1/25, states, in part; [...]
Inspectors wroteExample 2 R26 was admitted to the facility on [DATE] with diagnoses that include in part: Cerebral Palsy (a group of neurodevelopmental disorders that affect body movement and muscle coordination), Type II Diabetes, Spinal Stenosis, lumbar region with neurogenic claudication (A condition where the spinal canal narrows, compressing spinal nerves and causing leg pain, particularly when walking), Gastro-Esophageal Reflux, and other fatigue. R26's Most recent MDS (Minimum Data Set), with a target date of 3/20/25, indicates a BIMS (Brief Interview for Mental Status) score of 15, meaning R26 is cognitively intact. On 6/3/25 at 1:03 PM, during the record review portion of the initial pool process, surveyor was unable to locate all weights for trending weight loss or gain. On 6/4/25 at 7:30AM the facility provided the following list of weights for R26 from 1/1/25 to present: 1/1/25: [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate staffing to maintain residents highest practicable, physical, mental and psychosocial well-being. This affected 2 of 2 sampled residents (R47 and R24) and 1 of 1 supplemental residents (R29) reviewed for staffing. This has the potential to affect more than a limited number of residents residing in the home. Resident's voiced concerns regarding long call light wait times. Observations were made of no staff on the 200 hall for 45 minutes. Surveyor observed 45-minute call light wait time. Evidenced by: The facility policy, Call Lights: Accessibility and Timely Response, dated 2/1/25, states, in part; .The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 4 of 5 supplemental residents (R14, R15, R25,and R35 ), 3 of 6 medication carts, and 1 of 2 medication storage rooms. R14's eye drops were not dated with an open date. R15's eye drops were not dated with an open date and were not stored in the refrigerator. R25's Anbesol has no expiration date. R35's eye drops were past the discard date. The facility's 200-hallway medication cart had a loose pill in the top drawer and unlabeled medication. The facility's 300-hallway medication cart had loose pills in the top drawer and expired stock medication. The facility's 600-hallway medication cart had unlabeled insulin in the top drawer. [...]
Inspectors wroteExample 4 On 6/3/25 at 8:25AM Surveyor interviewed R53 as part of the initial screening process. R53 indicated the hot food is not always hot. R53 indicated the french fries are usually cool, sometimes potato dishes and wedges are almost raw, and noodles are not hot enough. R53 indicated this happens 1 to 2 times a week. Based on observation, interview, and record review, the facility did not ensure that food was palatable and at a safe and appetizing temperature for 4 of 15 residents (R46, R24, R53 and R12) who had specific complaints about food quality and serving temperature and 1 of 1 test trays were unpalatable. Residents voiced concerns about hot foods being served cold. Surveyor observed hot foods not hot and cold foods not cold on 1 of 1 test trays. Evidenced by: The facility policy, Food Temperature, no date, states, in part; .1. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure the right to request, refuse and/or discontinue treatment and to formulate an advanced directive for 2 of 25 Residents (R34 and R53). R34 and R53's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by: The facility policy titled, Residents' Rights Regarding Treatment and Advanced Directives, with an implementation date of 2/1/25, indicates, in part: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives . Policy Explanation and Compliance Guidelines: 1. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 residents reviewed (R67). R67 was placed in a low Broda chair (a specialty wheelchair that assists with positioning) that has brakes located on the back of the wheels at the bottom of the chair. R67's brakes were engaged while R67's was at the dining table, not allowing R67 to move the chair. Evidenced by: The facility's policy titled Restraint Free Environment dated 2/1/2025 states in part .Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 3 of 3 supplemental residents (R11, R381, & R52). R11 experienced a fall with a change of condition in which there was a delay of assessment of R11's right hip fracture. R381 had a change of condition and did not have documented assessments through the course of antibiotic treatment. R52 had a change of condition and did not have documented assessments through the course of antibiotic treatment. This is evidenced by: Surveyor requested facility's Change of Condition Policy. DON B states the facility does not have a Change of Condition policy but does follow AMDA (American Medical Directors Association) guidelines. [...]
Inspectors wroteBased on interview and record review, facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 3 (R33) residents reviewed for mobility/restorative programs. R33 was on a walking program this program this program was discontinued. R33 voiced frustration with not being in the walking program and wanting to walk. This is evidenced by: The facility's Screening and Restorative Policy, dated 3/4/24, states, in part: 1. Most new and readmissions will admit with therapy evaluation orders; however, for those that don't all new and readmissions should be screened to determine therapy needs.3. Restorative Program/Therapy to Nursing Communication form should be completed and dated.c. [...]
Inspectors wroteBased on interview and record review that facility did not ensure that residents acknowledge the understanding of an arbitration agreement and that they have just 30 days to rescind the arbitration agreement if they so choose after it is signed, this affected 1 of 1 sampled resident's (R73) and 1 of 2 supplemental residents (R430) reviewed for arbitration. R430 signed an arbitration agreement 5/29/25, R430 was not able to articulate understanding of the arbitration agreement and did not understand she had 30 days to change her mind. R73 signed an arbitration agreement 3/12/25, she did not know she only had 30 days to change her mind. This is evidenced by: The Facilities Policy and Procedure entitled Binding Arbitration Agreements dated 2/1/25, does not speak to the process of signing the document or the 30-day window to rescind. [...]
Inspectors wroteBased on interview and record review the facility did not report 1 (R5) of 2 allegations of abuse or neglect to the State Survey Agency during the required timeframe. An allegation of neglect involving R5 was not reported to the State Survey Agency within 24 hours of the allegation being made.
Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R5) of 2 allegations of abuse or neglect reviewed. R5 made an accusation of neglect on 4/29/2024 that was not thoroughly investigated.
Inspectors wroteBased on interview and record review the facility did not revise the resident plan of care with person centered interventions for 1 (R4) of 5 residents who's plan of care were reviewed. R4 had three orders on the Medication and Treatment Administration Record that were not carried through to the plan of care and/or [NAME] (a summary of patient information used frequently by certified nursing assistants).
Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 (R3 & R4) of 2 residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R3 & R4 were observed not wearing their palm protectors during the survey.
Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R3) of 1 residents who is fed by enteral means receives the appropriate treatment and services to prevent complication of enteral feeding. During personal care observations on 8/19/24 & 8/20/24, R3's head of the bed lowered flat while the tube feeding continued to be running. R3's Osmolite 1.5 was not running according to physician orders on 8/19/24 & 8/20/24. On 8/19/24, R3's water bag, Osmolite 1.5 container, and syringe were not labeled & dated. There is no assessment or order for R3's GT's (gastrostomy tube) secure device.
Inspectors wroteBased on record review and staff interview, the facility did not ensure 1 resident (R2) of 5 sampled residents had a medical record that contained complete and accurate information. The facility did not have R2's initial psychiatric consult and R2's talk therapy consult readily accessible for Surveyor to review. Findings Include: The facility's policy Health Information Management-Retention of Medical Records effective [DATE] documents: . Policy Statement: Protection and retention of medical records-The facility is responsible for protecting the Residents' medical records from loss, destruction or unauthorized use. The records must be retained for the period required by applicable state law and/or according to HIPPA guidelines. [...]
Inspectors wroteBased on observation, record review and interview, the facility did not have a process in place to ensure the high temperature dish machine was effectively washing and sanitizing the dishes for 1 of 1 dish machines in the kitchen which has the potential to affect all 84 residents within the facility. *The facility did not have a process in place to verify the temperature of the high temperature dish machine.
Inspectors wroteBased on observation, interview, and record review, many of the facility nursing staff were not fit tested for N95 masks to be worn in Covid-19 positive rooms. Laundry staff were not provided a hand washing station or personal protective equipment (PPE) of gowns or gloves in the dirty laundry sorting area. This has the potential to affect 84 of 84 residents the facility. -The facility last fit tested staff for N95 masks on 9/27/2023, staff hired after that date were not fitted to wear N95 masks in droplet precaution rooms. On 2/24/24 R76 returned from the hospital where R76 tested positive for COVID-19. R76 was placed in isolation and facility staff were required to wear Personal Protective Equipment (PPE) related to contact/droplet precautions while caring for R76. 16 of 20 staff who cared for R76 upon R76's return to the facility were not fit tested for their N95. [...]
Inspectors wroteBased on interview and record review, the facility did not make a prompt effort to resolve grievances for 6 (R70, R45, R40, R67, R28 & R73) of 6 residents who had voiced a grievance/concern to the facility. *On 2/27/24 during the resident council task, R70, R45, R40, R67 & R28 voiced that there have been multiple concerns brought forward related to facility food that have not been addressed. *On 2/27/24, R73 was observed to not be receiving their full general diet meal on their breakfast meal tray. Findings Include: On 2/27/24 at 11:35 AM, Surveyor completed the resident council meeting. Attendees of the resident council meeting conducted on 2/27/24 with Surveyor included R70, R45, R40, R67 & R28. During the resident council meeting, residents voiced that there have been multiple concerns brought forward related to facility food that have not been addressed. [...]
Inspectors wroteBased on interview, and record review the facility did not ensure quality of care was provided for 4 (R15, R64, R66, and R75) of 7 residents reviewed for neurological checks. * R15's neurological checks were not completed per facility policy after an unwitnessed fall on 10/7/2023. * R64's neurological checks were not completed per facility policy after an unwitnessed fall on 12/20/2023. * R66's neurological checks were not completed per facility policy after unwitnessed fall on 12/22/23. * R75's neurological checks were not completed per policy after two unwitnessed falls.
Inspectors wrote5. R15 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia, epilepsy, anxiety, arthritis, and type 2 diabetes mellitus. R15's admission minimum data set (MDS) dated [DATE] indicated R15 has moderately impaired cognition with a brief interview for mental status (BIMS) score of 9 and the facility assessed R15 needing maximal assist with one staff member using a gait belt and a two wheeled walker for ambulation and transfers. R15 was assessed on 10/27/2023 to be a high risk for falls with a fall risk score of 12. R15's risk for falls care plan was initiated on 10/16/2023 with the following interventions: - Be sure the resident's (R15) call light is within reach and encourage R15 to use it for assistance as needed. - Ensure that R15 is wearing appropriate footwear. (Initiated 10/19/2023) - Follow facility fall protocol. [...]
Inspectors wroteBased on observations, record review and staff interviews, the facility did not always ensure that they provided the necessary care and treatment to 2 out of 6 residents (R53, R5) reviewed with the necessary services to promote the healing of a pressure ulcer and to prevent new pressure ulcers from developing. * R53 has an unstageable pressure ulcer to her left heel which has been slowly healing since September, 2023. R53 was observed to not be offered the pressure relieving boots or pillow when she was assisted to bed. * R5 has a history of pressure ulcers and was assessed to be at high risk for redeveloping a pressure ulcer. R5 was observed laying in bed, on the special air mattress which was not powered on. This is evidenced by: Policy Review: AA Healthcare Management of Wounds, revised 7/25/16 Handout A- Pressure Ulcer Prevention Positioning devices: [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure consistent communication with a dialysis facility for 1 (R385) of 1 resident who received dialysis care and services. * R385 received dialysis three times a week. There are no communication forms between the facility and dialysis center on dialysis days resulting in inconsistent communication between the facility and the dialysis center.
Inspectors wroteBased on observation, interview, and record review, the facility did not comprehensively assess or develop a plan of care to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R78) of 5 residents reviewed for behavior management. R78 made statements regarding suicidal idealization and the facility did not update the plan of care or comprehensively assess the psychosocial needs of the resident to address suicidal statements.
Inspectors wroteBased on observation, interview, and record review the facility did not obtain and provide medications to meet the needs of each resident for 3 (R29, R12, and R41) of 6 residents observed during medication administration. * R29 did not have a probiotic available during medication administration observation. * R12 did not have a vitamin available during medication administration observation. * R41 did not have two inhalers available during medication administration observation.
Inspectors wroteBased on interview and record review the facility did not ensure the physician acted upon recommendations by the pharmacist for 1 (R64) of 5 residents reviewed for unnecessary medications. * Pharmacy recommendations were noted on 9/29/2023 for R64 to DC (discontinue) Melatonin 5mg QHS (every hour of sleep/ bedtime) and start Melatonin 3mg by mouth once daily with supper for insomnia. These pharmacy recommendations were not followed up on.
Inspectors wroteBased on interview and record review the facility did not ensure 1 (R64) of 5 residents drug regime was free from unnecessary medications. * R64 receives an anticoagulant (Eliquis) in which the facility is not adequately monitoring and there is no care plan in place to address the use of the anticoagulant.
Inspectors wroteBased on observation, interview, and record review, the facility did not assure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable and medications were not labeled when opened or include a resident's name in 2 of 3 medication carts reviewed for compliance. Surveyor observed undated, opened inhalers and eye drops, expired medications, and unlabeled medications in medication carts located on the 300 unit and 100 unit.
Inspectors wroteBased on observation, interview and record review the facility did not prepare mechanically altered food appropriately for 2 of 2 residents who receive puree texture food. * Cook-I did not use a recipe to prepare puree ham and broccoli.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure 1 of 5 residents (R2) reviewed for abuse was free from sexual abuse. The facility did not ensure R2 was free from sexual abuse by another resident (R4). On 12/4/23, CNA (Certified Nursing Assistant)-D observed R4 kissing R2 on the lips and requesting R2 to open her mouth so that he could stick his tongue in it and putting his hand on R2's groin. The facility investigation which included police involvement revealed R2 did not consent to R4's sexual behavior. During Surveyors' investigation, R2 became agitated to questions posed regarding R4 and indicated she was fearful of R4 with R4 aggravating her and entering her room on 12/18/23 after the incident of sexual abuse occurred on 12/4/23. [...]
Inspectors wroteBased on observation and interview the facility did not provide a safe, clean, comfortable home-like environment which had the potential to affect all 18 residents on the 200 pod and those residents that use the community conference/meeting room. On the 200-pod multiple resident rooms had dirt build up on the floors around the doorway to each room, floors were observed with dark stains, cracked tile. Liquid spills observed on lower half of the walls around the center of the pod area, shadow boxes outside of each resident room some were without protective glass or broken glass; overhead light fixtures with multiple dark spots on each overhead fixture and numerous bugs crawling on the walls and dead bugs on the floor of the facility conference/meeting room.
Inspectors wroteBased on interviews and record review, the facility did not ensure 1 of 2 residents (R1) reviewed for allegations of sexual abuse were provided a thorough investigation after the alleged violation. The facility's self-report dated 12/11/23 indicates R1 woke up with her brief open and alleged she was raped. The facility did not investigate possible medical concerns causing R1's vulvar pain. The facility did not conduct a thorough investigation into R1's allegation of rape to determine if there was a physical condition contributing to R1's allegation. In addition, on the same date as R1's allegation of rape, on 12/4/23, the facility became aware of an allegation of sexual abuse between two additional residents (R2 and R4). There is no evidence the facility considered if there was any correlation between the two allegations, both alleging sexual abuse.
Inspectors wroteBased on interview and record review the facility did not ensure 1 (R1) of 1 resident reviewed received the necessary care and treatment for vulvar pain and vaginal bleeding. The facility did not follow up with recommendations for R1 to schedule a Gynecological follow up appointment for uterine bleeding and vulvar pain.
Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure 1 of 5 residents (R2) reviewed for abuse was provided medically related social services to assist R2 in attaining or maintaining their mental and psychosocial health. * On 12/4/23, R2 was sexually abused by R4 who attempted to kiss and stick his tongue in her mouth, while grabbing R2's groin. The facility did not provide R2 with medically related social services for R2 to attain or maintain her highest practicable psychosocial well-being. R2 expressed to Surveyors being afraid of R4. In addition, R2 informed the police that the sexual abuse occurring on 12/4/23 was not consensual. There was no facility follow up with R2 to discuss her comfort with present room arrangements, there was no care plan updates to ensure R2 was free from potential further abuse from R4. [...]
Inspectors wroteBased on interviews and record review, the facility did not ensure 1 (R4) of 1 residents reviewed had adequate indications for use of an antidepressant medication (Paxil). R4 was prescribed an antidepressant medication without adequate indications for use.
Inspectors wroteBased on interviews, record review, facility document and policy review, the facility failed to implement new interventions after an elopement for 1 (R15) of 2 sampled residents reviewed for elopement.
Inspectors wroteBased on interviews, record reviews, and facility document and policy review, the facility failed to provide social services assistance for 1 (R6) of 3 residents reviewed for social services.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure Residents received care, consistent with professional standards of practice, to prevent pressure ulcers, and residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 2 (R76 and R244) of 7 Residents reviewed for pressure injuries. * R76 was admitted to the facility on [DATE] with documented open areas on buttock stage 2 pressure injuries. On 10/28/22, the facility implemented a skin integrity care plan indicating R76 was admitted with an unstageable pressure injury to the sacrum. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure 7 (R74, R15, R12, R244, R47, R90, and R49) of 7 residents reviewed that required hospitalization were provided with a written transfer notice which included the date of the transfer, location of transfer, and the reasons for the transfer with appeal rights. The facility did not ensure the resident/representatives received a completed transfer notice. *R74 was transferred to the hospital on 7/30/22 and R74 and her representative did not receive written notification of transfer or appeal rights. *R15 was transferred to the hospital on 9/5/22, 10/5/22, and 10/15/22 and R15 and his representative did not receive written notification of transfers to the hospital and appeal rights. [...]
Inspectors wroteBased on record review and interview, the facility did not ensure 4 (R49, R42, R47 and R84) out of 5 residents reviewed, were given psychotropic medications for valid reasons, with appropriate behavioral interventions and adequate monitoring. * R49 was administered scheduled risperidone, sertraline, and as needed ativan with no indications for use identified or behavior monitoring completed. * R42 was administered scheduled buspirone and aripiprazole with no indications for use identified or behavior monitoring completed. * R47 was administered scheduled risperidone and sertraline with no indications for use identified or behavior monitoring completed. * R84 was administered scheduled buspirone, zyprexia and sertraline with no indications for use identified or behavior monitoring completed. R84 did not have a screening/assessment for tardive dyskinesia completed with the use of Zyprexia.
Inspectors wroteBased on interview and record review, the facility failed to provide the needed care and services to meet the resident's physical needs for 1 (R47) of 6 residents reviewed for change of condition. R47 presented with respiratory disease-like symptoms, R47's physician was updated and ordered a CBC (Complete Blood Count) and a BMP (Basic Metabolic Panel) lab work which was not completed as ordered. R47's condition deteriorated and R47 was subsequently sent to the hospital.
Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 (R84) of 2 residents reviewed for accidents. R84 sustained a fall that resulted in R84 being transferred to the hospital due to a head laceration and need for sutures. The facility did not identify the root cause of the fall and did not implement person centered fall prevention interventions to addressed the root cause and prevent future falls.
Inspectors wroteBased on interview and record review, the facility did not ensure that residents who require dialysis received such services, consistent with professional standards of practice and the comprehensive person centered care plan for 1 (R51) of 2 Resident reviewed who receive dialysis care and services. The facility did not complete dialysis center communication forms to allow for ongoing communication and collaboration with the dialysis facility regarding R51's dialysis care and services.
Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R37) of 1 residents receiving insulin medication had the insulin identified with a pharmacy label and date of when the insulin was opened. On 12/1/22, during medication pass observation, Registered Nurse (RN)-F prepared R37's insulins. RN-F attempted to give R37 lispro insulin pen with R142's labeled insulin pen. Prior to administering the insulin, Surveyor pointed out the label to RN-F. RN-F then went back to the medication cart to look for R37's insulin pen. RN-F identified and pulled out 2 other insulin pens that did not have a pharmacy label with the resident's name on it.
Inspectors wroteBased on observation, interview and record review the facility did not maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R74 and R37) of 18 residents reviewed for infection control. *R74's catheter bag was observed lying directly on the floor. *RN (Registered Nurse)-F was observed attempting to give R37 insulin from an insulin pen labeled for a different resident. Findings Include: 1.) The Facility Policy and Procedure titled: Urinary Catheter Care, dated 05/3/2022, documents (in part) . Purpose: To establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Guidelines: . 7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. [...]
25 fire safety citations on file: 12 on June 9, 2025, 7 on March 4, 2024, 6 on December 1, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| December 26, 2023 | Fine | $95,791 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Wisconsin | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.28 | 4.21 | 3.86 |
| Registered nurses | 0.51 | 0.99 | 0.69 |
| All nursing staff on weekends | 2.84 | 3.77 | 3.42 |
| Nurse aides | 1.90 | ||
| Licensed practical nurses | 0.87 | ||
| Nursing staff turnover (share who left in a year) | 43.3% | 46.9% | 45.8% |
| Registered nurse turnover | 37.5% | 39.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.99 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.46 on weekdays and 2.84 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.58 in April to June 2025 to 3.28 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.28 | 0.51 | 3.46 | 2.84 | 0.0% | 0 of 90 | 89 |
| Oct to Dec 2025 | 3.50 | 0.39 | 3.68 | 3.04 | 0.0% | 1 of 92 | 84 |
| Jul to Sep 2025 | 3.42 | 0.31 | 3.64 | 2.88 | 0.0% | 0 of 92 | 88 |
| Apr to Jun 2025 | 3.58 | 0.35 | 3.82 | 3.00 | 0.0% | 0 of 91 | 88 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Wisconsin, Jan to Mar 2026 | 4.19 | 0.95 | 4.36 | 3.74 | 8.8% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Wisconsin, all employers | |||
| CNAs (nursing assistants) | $21.70 | $19.03 to $22.75 | 28,370 |
| LPNs and LVNs | $30.65 | $28.67 to $36.06 | 7,390 |
| Registered nurses | $45.93 | $39.39 to $49.33 | 68,060 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Wisconsin | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 5.5 | 16.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.9 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.1 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.3 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 6.5 | 18.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.6 | 5.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.8 | 15.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 27.5 | 23.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 20.1 | 15.5 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Avina of Pewaukee's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (39.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
39.4% this home
No different from the national rate
US median of homes 51.5% · Wisconsin: 52 better, 26 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 88 eligible stays.
8.8% this home
No different from the national rate
US median of homes 10.7% · Wisconsin: 0 better, 6 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 97 eligible stays.
5.8% this home
No different from the national rate
US median of homes 7.1% · Wisconsin: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 53 eligible stays.
18.8% this home
Median of homes: Wisconsin54.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 32 residents counted.
0.0% this home
Median of homes: Wisconsin0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 54 residents counted.
6.4% this home
Median of homes: Wisconsin2.2% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 54 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Wisconsin100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 18 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: CCC OF PEWAUKEE LLC. CMS links this home to Avina Healthcare, a group of 9 nursing homes averaging 2.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Brandman, Akiva | 5% or greater direct ownership interest | Individual | 10% | 11/01/2018 |
| Brandman, Yaakov | 5% or greater direct ownership interest | Individual | 10% | 11/01/2018 |
| Rebel, Igor | 5% or greater direct ownership interest | Individual | 20% | 11/01/2018 |
| Topper, Cecilia | 5% or greater direct ownership interest | Individual | 16% | 07/09/2024 |
| Brandman, Joseph | Operational/managerial control | Individual | 11/01/2018 | |
| Topper, Aaron | Operational/managerial control | Individual | 11/01/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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