Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Avina of Pewaukee
Waukesha, WI · 120 certified beds · Last Life Safety survey August 7, 2026
CMS Certification Number 525646 · first certified July 1998
Ownership
Operated by AVINA HEALTHCARE · For profit - Corporation
- Ownership changed November 1, 2018 (change of ownership)from HEARTLAND-PEWAUKE OF WAUKESHA WI LLC
Position within WI
27 citations — more than 77% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys on file averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2027 — about 10 months from now. This facility’s last Life Safety survey was August 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 519 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 4, 2024 | 7 |
| June 9, 2025 | 12 |
| August 7, 2026 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-08-07 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-06-09 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2026-08-07 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2026-08-07 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2026-08-07 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2026-08-07 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2026-08-07 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2025-06-09 |
What the citations cover
- Smoke Deficiencies 12
- Miscellaneous Deficiencies 4
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Miscellaneous Deficiencies | 4 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 7, 2026 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (August 18, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 20, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (September 20, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 18, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 18, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 26, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 26, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 20, 2026) |
June 9, 2025 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 31, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 25, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 2, 2025) |
March 4, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 12, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (March 26, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 26, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 26, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 10, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 10, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 26, 2024) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.