Avina of Pewaukee

In the surveyor’s words

From the most serious findings on record at Avina of Pewaukee, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 26, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF684Oct 21, 2021

  Based on record review and interview, the facility failed to recognize a change in condition and failed to react timely and provide care consistent with professional standards of practice for 1 (R1) of 3 residents reviewed for a change in condition. R1 became unresponsive on 10/2/2021. Licensed Practical Nurse (LPN)-H and Registered Nurse (RN)-C did not seek immediate attention to address the change in condition. RN-C did not immediately call 911, but instead called a local ambulance company approximately 45 minutes after discovering R1 in an unresponsive condition. […]

• Actual harm, isolatedF686Dec 1, 2022

  Based 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. […]

• Actual harm, isolatedF686Apr 14, 2021

  Based on observation, record review and staff interview, the facility did not ensure that a resident (R3) received care consistent with professional standards of practice to prevent pressure injuries and also a resident with a pressure injury (R14) received necessary treatment and services to promote healing for 2 of 5 sampled residents. * R3 was admitted to the facility without pressure injuries. The facility assessed R3 to have been at moderate risk of developing pressure injuries upon the resident's admittance to the facility. The facility did not develop nor implement interventions to prevent pressure injuries. […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2026

  Based on observation, interview, and record review, the facility failed to ensure the walk-in freezer was maintained in proper operating condition to prevent excessive ice and frost accumulation. This deficient practice had the potential to affect food storage conditions by contributing to unsafe food temperatures, thereby increasing the risk for foodborne illness. Findings include: During kitchen tours on 08/04/26 at 8:46 AM with the Dietary Assistant (DA) present, and on 08/05/26 at 2:10 PM with the Dietary Manager (DM) present, the walk-in freezer was observed to have heavy ice and frost accumulation on the interior vinyl door strips, floor areas extending to the shelving, and large ice formations on the inside of the door. […]