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CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
The Waters of Pewaukee is a highly regarded retirement community in Pewaukee, WI, that offers independent living, assisted living, and memory care. Featuring a variety of studio to two-bedroom accommodations in a nurturing and welcoming environment, the community ensures older adults can find a home away from home. A 24-hour emergency response, various dining options, and concierge services are also provided to enrich residents’ living experiences. The community also doubles its efforts to understand residents’ unique needs and preferences to provide the best possible care.
Fitness classes, educational programs, and cultural events help residents stay active and make new friends. A dog park, beautiful courtyards, and a wellness center are among the state-of-the-art amenities available for residents’ leisure and wellness. With its convenient location near downtown Milwaukee and the Pewaukee Lakefront, the community ensures residents have easy access to their leisure and necessities. This retirement community has a wide range of services and top-notch amenities, making it one of the best choices for senior living in Wisconsin.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 130th out of 172 homes in Wisconsin for nurse hours. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 23m per day | ▼ 61% State avg: 59m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 1h 2m per day | ▲ 59% State avg: 39m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 5m per day | ▼ 19% State avg: 2h 34m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 3m per day | ▼ 19% State avg: 3h 45m per day · National avg: 3h 27m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 3m per day | ▼ 11% State avg: 4m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 13m per day | ▼ 66% State avg: 40m per day · National avg: 29m per day |
Higher than the Wisconsin average: 70%The Waters of Pewaukee is legally operated by Jonathan Glass, and administrated by Shp Vi Wslg Pewaukee Jv LLC.
Key information about the people who lead and staff this community.
In Wisconsin, the Department of Health Services, Division of Quality Assurance performs unannounced onsite surveys to ensure that long-term care facilities meet health and safety laws.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Wisconsin state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | WI Average | vs. WI Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 4 | 12 | This facility has 67% fewer total deficiencies than a typical Wisconsin nursing home (4 vs. WI avg 12).↓ 67% better |
|
Deficiencies per year
Average deficiencies per year since 2025.
| 4 | 12 | This facility has 67% fewer deficiencies per year than a typical Wisconsin nursing home (4 vs. WI avg 12).↓ 67% better |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 4 | 2 | This facility has 100% more deficiencies per inspection than a typical Wisconsin nursing home (4 vs. WI avg 2).↑ 100% worse |
Inspections
| This Facility | WI Average | vs. WI Avg |
|---|---|---|---|
|
Total inspections
Combined count of all routine and focused inspections. Excludes complaint investigations.
| 1 | 6 | This facility has 83% fewer total inspections than a typical Wisconsin nursing home (1 vs. WI avg 6).↓ 83% better |
Wisconsin average 6
Last Health inspection on Jul 2025
Wisconsin average 27.3
Wisconsin average 4.19
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
28 of 53 citations resulted from standard inspections; 18 of 53 resulted from complaint investigations; and 7 of 53 came from combined inspections (standard and complaint).
11% worse than Wisconsin averageWisconsin average: 0.9
17% better than Wisconsin averageWisconsin average: 1.2
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
44% fewer staff per resident than Wisconsin average
0% compared with Wisconsin average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
All 5 RN Staff are full-time employees. No contractors work on this role.
5
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.2 hoursAssists with medical care and medications.
All 14 LPN Staff are full-time employees. No contractors work on this role.
14
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.4 hoursHelps with daily care and mobility.
All 55 CNA Staff are full-time employees. No contractors work on this role.
55
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.5 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
2,389 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 55 | 0 | 55 | 14,231 | 92 | 100% | 7.5 |
| Licensed Practical Nurse | 14 | 0 | 14 | 6,029 | 92 | 100% | 8.4 |
| Registered Nurse | 5 | 0 | 5 | 2,033 | 91 | 99% | 8.2 |
| RN Director of Nursing | 5 | 0 | 5 | 1,944 | 86 | 93% | 7 |
| Medication Aide/Technician | 5 | 0 | 5 | 1,912 | 92 | 100% | 7.2 |
| Other Dietary Services Staff | 6 | 0 | 6 | 1,218 | 89 | 97% | 7.1 |
| Mental Health Service Worker | 2 | 0 | 2 | 912 | 62 | 67% | 8 |
| Physical Therapy Assistant | 0 | 5 | 5 | 528 | 71 | 77% | 7.2 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 525 | 63 | 68% | 6 |
| Physical Therapy Aide | 0 | 4 | 4 | 524 | 74 | 80% | 6.6 |
| Qualified Social Worker | 0 | 3 | 3 | 506 | 68 | 74% | 7.2 |
| Dietitian | 1 | 0 | 1 | 472 | 59 | 64% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 448 | 56 | 61% | 8 |
| Administrator | 1 | 0 | 1 | 432 | 54 | 59% | 8 |
| Respiratory Therapy Technician | 0 | 8 | 8 | 432 | 78 | 85% | 5.4 |
| Speech Language Pathologist | 0 | 4 | 4 | 399 | 67 | 73% | 5.9 |
Includes penalties issued in 2023
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
In line with Wisconsin averageWisconsin average: $95K
52% fewer fines than Wisconsin averageWisconsin average: 2.1
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than Wisconsin averageWisconsin average: 0.7
Penalties are imposed by CMS for violations of federal nursing home regulations.
1 penalty in the past 3 years
Dec 26, 2023 · $96K
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Dec 26, 2023Last updated: Jan 2026
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
4.6
56% better than Wisconsin averageWisconsin average: 10.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
10.5
52% better than Wisconsin averageWisconsin average: 22.1
Percent of long-stay residents whose need for help with daily activities has increased
6.5%
63% better than Wisconsin averageWisconsin average: 17.6%
Percent of long-stay residents whose ability to move independently worsened
6.1%
73% better than Wisconsin averageWisconsin average: 22.8%
Percent of low risk long-stay residents who lose control of their bowels or bladder
19.0%
27% better than Wisconsin averageWisconsin average: 26.0%
Percent of long-stay residents experiencing one or more falls with major injury
0.7%
79% better than Wisconsin averageWisconsin average: 3.2%
Percent of long-stay high risk residents with pressure ulcers
3.8%
31% better than Wisconsin averageWisconsin average: 5.4%
Percent of long-stay residents with a urinary tract infection
1.4%
58% better than Wisconsin averageWisconsin average: 3.2%
Percent of long-stay residents who lose too much weight
5.9%
22% worse than Wisconsin averageWisconsin average: 4.9%
Percent of long-stay residents who have depressive symptoms
1.5%
71% better than Wisconsin averageWisconsin average: 5.0%
Percent of long-stay residents who received an antipsychotic medication
15.3%
5% better than Wisconsin averageWisconsin average: 16.1%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
96.0%
In line with Wisconsin averageWisconsin average: 95.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
95.5%
In line with Wisconsin averageWisconsin average: 95.0%
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
85.6%
In line with Wisconsin averageWisconsin average: 87.3%
Percent of short-stay residents who newly received an antipsychotic medication
2.7%
114% worse than Wisconsin averageWisconsin average: 1.2%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
72.9%
11% worse than Wisconsin averageWisconsin average: 82.2%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
20% of new residents, usually for short-term rehab.
80% of new residents, often for short stays.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
87Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Waters of Pewaukee based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #52 / 177Payroll — State benchmarkedThis home is ranked 52nd out of 177 homes in Wisconsin for payroll. Shows total annual staff payroll benchmarked to the Wisconsin average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Room Sizes: 429-461 / 643-913 / 967-1234 / 1764-2001 sq. ft
Housing Options: Cottage / Studio / 1 Bed / 2 Bed
Building Type: 3-story
Transportation Services
Fitness and Recreation
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
4.7 miles from city center
Estimated distance in miles from Waukesha's city center to The Waters of Pewaukee's address, calculated via Google Maps.
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The Waters of Pewaukee is located in Waukesha, Wisconsin.
Here are the financial assistance programs available to residents in Wisconsin.
The Waters of Pewaukee is in the City of Pewaukee neighborhood of Waukesha.
The legal owner and operator of The Waters of Pewaukee is Jonathan Glass.
The Waters of Pewaukee has a walk score of 13. Car-dependent. Most errands require a car, with limited nearby walkable options.
The Waters of Pewaukee's occupancy is 100%.
SHP VI WSLG Pewaukee JV LLC is the administrator of The Waters of Pewaukee.
The Waters of Pewaukee has 16 beds.
Yes — there are 4 photos of The Waters of Pewaukee in the photo gallery on this page.
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