Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aria Of Waukesha during CMS and state inspections, most recent first.
A resident with respiratory failure, heart failure, muscle weakness, and significant mobility limitations was discharged home without a documented discharge summary, care conference notes, or verification that discharge goals were met. Although the care plan called for evaluating the resident’s ability to return to the community and therapy recommended home health services, there was no record that referrals were initiated, completed, or formally declined by the resident, who was cognitively intact. Discharge planning discussions and care conferences were not documented in the medical record, a paper discharge checklist was kept outside the record, and the facility relied on information from a family member without verifying it with the resident or documenting the availability and capability of caregivers or the safety of the discharge environment.
A resident with hemiplegia, epilepsy, and dependence for showering was care planned to receive assisted showers twice weekly and as needed, consistent with facility bathing policy. The resident reported no longer receiving regular Monday showers and believed her last shower had been about two weeks earlier, and later described a very brief shower that was essentially a quick rinse. Review of electronic POC records over the prior month showed multiple scheduled shower days marked as not applicable, one bed bath without explanation, one refusal, and several dates with no shower documentation at all, despite a census list indicating specific shower days. When the surveyor compared the POC records viewed onsite with a later printed copy, additional shower check marks appeared on dates that had not previously shown showers, and the facility did not provide a clear explanation for the missed showers or the altered documentation.
A resident with cognitive impairment and a history of agitation was not properly assessed for elopement risk, resulting in the absence of necessary interventions such as a Wanderguard and targeted care planning. The facility's main entrance was left unmonitored and unalarmed during early morning hours, allowing the resident to leave unnoticed. The resident was found several hours later and miles away, highlighting failures in both assessment and supervision.
The facility failed to employ a qualified Dietary Manager or full-time nutritional professional, leading to inadequate menu planning and resident dissatisfaction with breakfast offerings. The DM, not certified, was responsible for menus and inventory, while the RD provided limited consultative work. Residents expressed concerns about the lack of meat in breakfast meals, which the DM was unaware of. The DON and Administrator confirmed the RD's consultant role and the DM's responsibility for menu planning.
The facility failed to maintain sanitary conditions in a resident refrigerator, leading to a buildup of ice and frost and the presence of unlabeled and undated food items. A resident reported the issue, and observations confirmed the unsanitary conditions. Interviews revealed a lack of clarity regarding responsibility for maintaining the refrigerator, with the DON and Administrator acknowledging the oversight.
A facility failed to ensure staff donned appropriate PPE for a resident on Enhanced Barrier Precautions. A nurse did not wear a gown while performing wound care, despite signage indicating the need for gowns and gloves. The resident had a stage IV pressure ulcer, an indwelling urinary catheter, and a feeding tube. The DON confirmed the expectation for staff to follow EBP, and the nurse attended training after the incident.
The facility did not follow its policies for conducting timely caregiver background checks, resulting in a Laundry Aide working before checks were completed and a CNA's checks not updated upon transfer. The HR Director and Regional Director confirmed the oversight, and the NHA acknowledged the failure to perform necessary checks.
Failure to Document and Coordinate Safe Discharge Planning and Home Health Referrals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that discharge planning for one cognitively intact resident included documented coordination of services, resident participation, and verification of a safe and appropriate transition to the community. The facility’s own Discharge Planning policy requires timely documentation of discharge needs and plans, discussion of the evaluation results with the resident or representative, and development of a post-discharge plan of care indicating the discharge location and arrangements for follow-up care and services. For this resident, the medical record did not contain a completed discharge summary, documentation of a care conference discharge meeting, or confirmation that post-discharge needs and services were fully addressed prior to discharge. The only progress note related to discharge indicated that the resident was discharged home with paperwork and medications, that van transport arrived, and that a family member was waiting at the destination. The resident was admitted with respiratory failure, cognitive communication deficit, heart failure, and muscle weakness, and had significant functional limitations requiring substantial/maximal assistance with transfers and dependence for walking at admission. At discharge, the MDS showed the resident remained cognitively intact with a BIMS score of 13, required partial/moderate assistance for sit-to-stand and bed-to-chair transfers, and was not assessed for car transfer or walking 10 feet due to medical or safety concerns. The care plan documented that the resident wished to discharge home or to the community, with interventions to evaluate the resident’s motivation and ability to safely return to the community and to identify gaps in abilities affecting discharge. However, there was no documentation that these evaluations and care plan interventions were completed or that discharge goals were met before the resident left the facility. Interviews with staff revealed that the social worker managed discharge planning and home health referrals but did not document care conferences or discharge planning discussions in the medical record, instead keeping and then deleting personal notes. The LPN reported that nursing’s role in discharge was limited to belongings and medication management, that a paper discharge checklist was used but not part of the medical record, and that the discharge was “fast and abrupt” once insurance ended. The OT stated that therapy determined the resident was not appropriate to live alone at discharge, recommended home health services, and communicated these recommendations to the social worker, but the medical record contained no documentation that home health referrals were initiated, completed, or formally declined by the resident. The social worker reported that a phone conversation with the resident’s brother led to not sending the home health referral, based on the brother’s reluctance to have services in the home and his statement that family would assist, but this was not documented, and the facility did not verify this information with the resident, who was his own decision maker. There was no documentation confirming the adequacy of caregiver support or the safety of the discharge environment, and leadership acknowledged that the expected discharge summary, care conference documentation, and follow-through on therapy referrals were not present in the record.
Failure to Provide and Accurately Document Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, as outlined in facility policy and the resident’s care plan. The resident, admitted with hemiplegia and hemiparesis following a cerebral infarction, epilepsy, and neuralgia/neuritis, had a BIMS score of 14 indicating no cognitive impairment but was documented as dependent for showering/bathing in the MDS. The resident’s care plan and Kardex required assistance from two staff for bathing/showering twice weekly and as needed. Facility policy required that all residents be offered a bath or shower at least weekly or per preference, and that refusals be reported to a nurse and documented by a licensed nurse. During an interview, the resident reported needing help with ADLs and stated that she previously received a shower every Monday but no longer did, estimating her last shower was about two weeks prior. She also expressed a preference for showers before 10:00 AM. On the same day, the surveyor found the resident’s call light not working for at least an hour while the resident was crying, needed changing, and requested ice water. Later that morning, staff were observed wheeling the resident back from a shower; afterward, the resident reported that the shower lasted about two minutes and that she was only rinsed with water. Review of the Point of Care (POC) bathing/shower documentation for the prior 30 days showed multiple dates on which the resident’s scheduled shower days were marked as “not applicable,” with no documentation that a shower occurred, and one date with a bed bath documented without explanation for why a shower was not provided. One date showed a refusal, but other scheduled shower days had no documentation of a shower or refusal. When the surveyor later compared printed POC shower documentation to what had been viewed onsite, there were discrepancies, including added check marks under “shower” on dates that had not previously shown showers. The facility did not provide documentation that the resident consistently received showers as care planned on all scheduled days, nor an explanation for the discrepancies in shower documentation or for the missed showers for a resident unable to perform ADLs independently.
Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and accident prevention for a resident with cognitive impairment and a history of agitation and confusion. Upon admission, the resident had diagnoses including encephalopathy, vascular dementia, and mood disturbances, and had demonstrated agitation and a desire to leave home prior to admission. Despite this, the facility's elopement risk assessment was completed incorrectly, omitting points for mobility status and being new to the facility, resulting in the resident not being identified as at risk for elopement. Consequently, the resident was not provided with a Wanderguard or specific interventions to prevent elopement, and the care plan did not address elopement risk or the resident's ongoing expressions of wanting to leave. The facility's monitoring procedures were insufficient, particularly at the main entrance. The front doors were unlocked during early morning hours before the reception area was staffed, and there was no alarm or staff presence to monitor residents exiting the building during this time. The resident was last seen in the early morning, and staff did not notice the absence until an hour later, at which point a search was initiated. The lack of supervision and monitoring allowed the resident to leave the facility unnoticed. The resident was found eight hours later, twenty miles away from the facility, after a Silver Alert was issued and family members assisted in the search. The resident sustained superficial abrasions and required evaluation in the emergency department. Interviews with staff confirmed gaps in the elopement risk assessment process, care planning, and entrance monitoring, all of which contributed to the resident's ability to elope from the facility without detection.
Removal Plan
- All facility residents were re-assessed to identify risk for elopement and ensure proper interventions were implemented.
- Identified residents at risk for elopement and ensure person centered care plans are in place with preventative measures to include the specified level of supervision for residents at risk for elopement.
- Reviewed elopement/missing resident policy to address the timing of searching for/reporting a missing resident to help ensure an expedited search.
- Education was provided to all staff on following the facility's updated elopement policy, accuracy of elopement assessments, monitoring resident's at risk for elopement and timely response to door alarms.
- Elopement risk assessments completed will be reviewed during clinical meeting to verify accuracy and ensure appropriate interventions were put in place.
- New elopement risk assessments were completed for all facility residents.
- Facility implemented cameras at facility entrance.
- Reviewed updated facility policy and procedure on elopement and coordination with medical director. Including updated elopement assessments, and addition of cameras at the facility entrance to ensure adequate resident supervision is in place to identify residents exiting the facility and to ensure facility policy and procedure meets current standard of practice.
- Facility Maintenance will complete audits to ensure door alarms are properly functioning. Audits will be completed on all shifts.
- IDT will review in clinical meeting any new admissions elopement assessments, incidents regarding changes in residents' behaviors, and document on eagle board to ensure proper assessments have been obtained and appropriate interventions have been implemented. Audits will be conducted. Results will be reviewed by QAPI Committee to determine compliance or additional follow up required.
- An Ad Hoc QAPI completed.
Deficiency in Dietary Management and Menu Planning
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM) or a clinically qualified nutritional professional on a full-time basis to oversee the menus, leading to concerns about kitchen management and menu planning. The DM, who has been in the role for about two years, confirmed she was not a Certified Dietary Manager and believed the facility had a full-time registered dietitian (RD). However, the RD was only a consultant providing three to four hours of remote consultative work per week. The DM was responsible for the menus, ordering, and maintaining inventory, while the RD was responsible for resident assessments. This lack of full-time qualified personnel resulted in inadequate menu planning, as evidenced by the repetitive breakfast menu lacking meat protein, which was a concern expressed by residents. Residents R25, R9, R11, and R49 expressed dissatisfaction with the breakfast menu, noting the absence of meat. During interviews, the DM was unaware of these complaints and stated that the RD was responsible for creating menus that met residents' nutritional needs. The facility's Director of Nursing (DON) and Administrator confirmed the RD was a consultant and that the DM was responsible for menu planning with the help of an automated program. They were unaware of the residents' dissatisfaction with the breakfast offerings. This situation highlights the deficiency in employing qualified staff to ensure the nutritional needs and preferences of residents are met.
Failure to Maintain Sanitary Conditions in Resident Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the East unit refrigerator, which was designated for resident use. During an interview, a resident reported that the refrigerator was unclean and required defrosting. Observations confirmed a significant buildup of ice and frost in the freezer section, along with unlabeled and undated items such as plastic soda bottles, leftover fast-food containers, and opened condiment containers. These conditions were contrary to the posted instructions on the refrigerator door, which required all items to be labeled, dated, and discarded after three days. Interviews with facility staff revealed a lack of clarity regarding responsibility for maintaining the cleanliness and organization of the refrigerator. The Director of Nursing (DON) indicated that dietary staff were responsible for cleaning, while nursing staff were tasked with labeling and dating items. However, the Administrator acknowledged that the facility had not assigned specific responsibility for cleaning the resident refrigerators, leading to the oversight. The facility's infection control policy emphasized the importance of maintaining a safe and sanitary environment to prevent infection, but this was not adhered to in the case of the East unit refrigerator.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned the appropriate personal protective equipment (PPE) when providing direct care to a resident on Enhanced Barrier Precautions (EBP). Specifically, a registered nurse (RN) did not wear a gown while performing wound care on a resident with a stage IV sacral pressure ulcer, an indwelling urinary catheter, and a feeding tube. The resident's room had signage indicating the need for EBP, which includes wearing gowns and gloves during high-contact care activities. Despite this, the RN only wore gloves and was unaware that the resident was on EBP. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene and wear gowns and gloves when providing direct care to residents on EBP. The DON also stated that staff had recently been instructed on EBP precautions. However, the RN involved in the incident had attended a training session on EBP after the deficiency was observed, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Conduct Timely Background Checks for Staff
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse by not ensuring thorough and timely caregiver background checks for two staff members, a Laundry Aide and a Certified Nursing Assistant. The facility's Abuse Prevention Program mandates pre-employment screening, including obtaining a Wisconsin Criminal History Record and a caregiver background check before a new employee starts work. However, the Laundry Aide began working before these checks were completed, and the Certified Nursing Assistant's background checks were not updated upon transferring from a sister facility. The Human Resources Director and Regional Director of Clinical Operations confirmed that background checks should be completed before an employee's first shift and when transferring between facilities. Despite this, the Laundry Aide worked several shifts before the background checks were conducted, and there was no evidence of a national criminal background check for the Laundry Aide, who had previously resided in Florida. The Nursing Home Administrator acknowledged the oversight, confirming that the necessary checks were not performed as required by the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waukesha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Kensington | 2.5 mi | — | 1 | 0 |
| Avina Of Pewaukee | 2.7 mi | — | 5 | 0 |
| Lindengrove Waukesha | 2.7 mi | — | 20 | 1 |
| Complete Care At Care Age | 3.4 mi | — | 1 | 0 |
| Aria Of Brookfield | 3.9 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.