Inspection visit
Inspection
Citations
26 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0331GeneralS&S Dpotential for harm
Construct fire resistant interior walls.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F679 - Activities
Provide activities to meet all resident's needs.
F688 - Mobility
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.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F584 - Safe Environment
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.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F761 - Labeling of Drugs and Biologicals
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.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the June 9, 2025 survey of Avina of Pewaukee?
This was a inspection survey of Avina of Pewaukee on June 9, 2025. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Avina of Pewaukee on June 9, 2025?
Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop Emergency Preparedness policies and procedures."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.