Wisconsin › Waukesha County › Waukesha
Complete Care At Kensington
1810 Kensington Dr, Waukesha, WI 53188
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Complete Care At Kensington, in Waukesha, Wisconsin, is certified for 150 beds under for-profit, limited liability company ownership and belongs to the Complete Care chain.
CMS gives it 1 of 5 stars overall, below the Wisconsin median of 3; the health inspection rating is 2, staffing 1 and quality measures 3.
Inspectors recorded 32 health deficiencies across the three most recent survey cycles (5, 9, 18 by cycle, most recent first), 3 of them at the actual-harm or immediate-jeopardy level. That is 21.3 per 100 beds, fewer than the state median of 31.8.
CMS lists 1 penalty in the period covered: fines totalling $67K.
Reported nurse staffing is 3.5 hours per resident per day (0.6 RN), close to the Wisconsin median of 4.0; nursing staff turnover is 55.8%.
Compared with county, state and nation
| Measure | This facility | Waukesha Co. median | Wisconsin median | US average |
|---|---|---|---|---|
| Overall star rating | 1 | 1 | 3 | 3.0 |
| Health citations, 3 cycles | 32 | 37 | 21 | 28.7 |
| Citations per 100 beds | 21.3 | 45.5 | 31.8 | 26.8 |
| Total nurse hours per resident day | 3.5 | 4.1 | 4.0 | 3.9 |
| RN hours per resident day | 0.6 | 0.7 | 0.9 | 0.7 |
| Nursing staff turnover | 55.8% | 55.8% | 46.2% | 45.8% |
| Fines listed | $66,632 | $95,791 | $0 | — |
County and state figures are medians across facilities (17 in the county, 323 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Wisconsin average per facility for the same cycle, as published by CMS. Standard health survey dates: 29 Apr 2026, 21 May 2025.
Severity mix: J ×2 G ×1 D ×17 E ×5 F ×5 C ×2
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 29 Apr 2026 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F | Standard survey | 22 May 2026 |
| 29 Apr 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 22 May 2026 |
| 29 Apr 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 22 May 2026 |
| 29 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 22 May 2026 |
| 23 Feb 2026 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 20 Mar 2026 |
| 21 May 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0610 | Respond appropriately to all alleged violations. | D | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0687 | Provide appropriate foot care. | D | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Standard survey | 12 Jun 2025 |
| 21 May 2025 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | C | Standard survey | 12 Jun 2025 |
| 22 Feb 2024 | F0880 | Provide and implement an infection prevention and control program. | F | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident. | D | Complaint investigation | 15 Mar 2024 |
| 22 Feb 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 15 Mar 2024 |
| 22 Feb 2024 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0760 | Ensure that residents are free from significant medication errors. | D | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0761 | 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. | D | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0881 | Implement a program that monitors antibiotic use. | D | Standard survey | 15 Mar 2024 |
| 22 Feb 2024 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | C | Standard survey | 15 Mar 2024 |
| 30 Jan 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J | Complaint investigation | 15 Jan 2024 |
| 30 Jan 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 31 Jan 2024 |
| 30 Jan 2024 | F0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Complaint investigation | 13 Feb 2024 |
| 30 Jan 2024 | F0946 | Provide training in compliance and ethics. | F | Complaint investigation | 13 Feb 2024 |
| 30 Jan 2024 | F0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F | Complaint investigation | 13 Feb 2024 |
| 6 Oct 2023 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint investigation | 17 Oct 2023 |
| 6 Oct 2023 | F0558 | Reasonably accommodate the needs and preferences of each resident. | D | Complaint investigation | 17 Oct 2023 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 30 Jan 2024 | Fine | $66,632 |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Wisconsin average. Turnover: nursing staff 55.8%, RNs 50.0%; 1 administrator left in the reporting year.
Quality measures
| Measure | Residents | This facility | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 5.0% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.7% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.1% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.3% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 10.7% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.2% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 21.2% | 14.4% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, limited liability company. Legal business name: Waukesha Healthcare And Rehabilitation Center Llc. Chain: Complete Care (85 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Peace Capital LLC | 5% or greater direct ownership interest | 100% | 05/03/2024 |
| Des Capital LLC | Adp of the snf | NOT APPLICABLE | 08/01/2017 |
| Jrk Investments LLC | Adp of the snf | NOT APPLICABLE | 08/01/2017 |
| Wakesha Propco LLC | Adp of the snf | NOT APPLICABLE | 08/01/2017 |
| Wi 6 Propco Holdco LLC | Adp of the snf | NOT APPLICABLE | 08/01/2017 |
| Wi 6 Propco Topco LLC | Adp of the snf | NOT APPLICABLE | 08/01/2017 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Waukesha County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Masonic Center For Health & Rehab Inc. | Dousman | 50 | 5 | 5 | 5 | 3 | 6.0 | — | 29 Jan 2026 |
| Shorehaven Hlth & Rehab Ctr | Oconomowoc | 88 | 5 | 4 | 5 | 10 | 11.4 | — | 5 Mar 2026 |
| Congregational Home, Inc. | Brookfield | 66 | 4 | 3 | 5 | 21 | 31.8 | — | 31 Jul 2025 |
| Lake Country Health Services | Oconomowoc | 100 | 2 | 2 | 3 | 42 | 42.0 | $121K | 27 Aug 2025 |
| Lindengrove Mukwonago | Mukwonago | 47 | 2 | 3 | 4 | 25 | 53.2 | — | 10 Dec 2025 |
| Menomonee Falls Health Services | Menomonee Falls | 50 | 2 | 2 | 3 | 46 | 92.0 | $214K | 3 Dec 2025 |
| Muskego Health and Rehabilitation Center | Muskego | 49 | 2 | 2 | 3 | 56 | 114.3 | — | 28 Jan 2026 |
| Tudor Oaks Health Center | Muskego | 50 | 2 | 2 | 3 | 37 | 74.0 | $181K | 5 Dec 2025 |
All 17 facilities in Waukesha County
Questions and answers
How many deficiencies has Complete Care At Kensington been cited for?
32 health deficiencies across the three most recent survey cycles, 3 at the actual-harm or immediate-jeopardy level. The Wisconsin median is 21 per facility.
Has Complete Care At Kensington been fined?
Yes. CMS lists fines totalling $67K in the period covered.
How does staffing at Complete Care At Kensington compare?
Reported total nurse staffing is 3.5 hours per resident per day against a Wisconsin median of 4.0 and a national average of 3.9.
Who operates Complete Care At Kensington?
It is part of the Complete Care chain. Ownership type is for-profit, limited liability company. Organisations in the CMS ownership record include Peace Capital LLC. Individual owners and managers are not listed on this site.
When was Complete Care At Kensington last inspected?
The most recent survey or investigation in the CMS record is dated 29 Apr 2026; the most recent standard health survey was 29 Apr 2026.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.