Complete Care at Glendale West
Open-data reference.
Complete Care at Glendale West is a for profit - limited liability company facility in GLENDALE, WI with 94 certified beds and a 2-star overall CMS rating. The facility has 38 deficiency records on file. Total penalties: $11K.
6263 N GREEN BAY AVE, GLENDALE, WI 53209
Phone: 4143510543
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525547
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 94
- Residents
- 78
- In Hospital
- No
- County
- Milwaukee
- Last Inspection
- May 22, 2025
Staffing Data
- RN Hours
- 0.66 (nat'l avg: 0.68)
- LPN Hours
- 0.71
- CNA Hours
- 2.72
- Total Nursing Hours
- 4.08 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 44.0%
- RN Turnover
- 25.0%
What the CMS Record Reveals About Complete Care at Glendale West
Complete Care at Glendale West operates 94 certified beds in GLENDALE, WI with approximately 78 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (3★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 38 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $11K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.08 total nursing hours per resident day (national average 3.89), with RN coverage at 0.66 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Complete Care at Glendale West falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 44.0%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (38 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 5, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 5, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 5, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Dec 5, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jun 22, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2025
Give residents a notice of rights, rules, services and charges.
Category: Resident Rights Deficiencies
Corrected: Jun 22, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jun 22, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 22, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jun 22, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2025
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 22, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 17, 2024
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Category: Resident Rights Deficiencies
Corrected: Dec 17, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 15, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 5, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jul 5, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 24, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 24, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 24, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 24, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 26, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 18, 2022
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: Nov 18, 2022
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Nov 18, 2022
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2022
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Category: Resident Rights Deficiencies
Corrected: Nov 18, 2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Nov 18, 2022
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Nov 18, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 8.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 9.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.3% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 90.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 74.4% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.6% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 13.7% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 13.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 84.8% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 24.5% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.5% | Yes |
Penalty History 1 penalties totaling $11K
| Date | Type | Amount |
|---|---|---|
| Nov 29, 2023 | Fine | $11K |
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for Complete Care at Glendale West?
What are the staffing levels at Complete Care at Glendale West?
How many beds does Complete Care at Glendale West have?
Does Complete Care at Glendale West have any deficiencies on record?
Has Complete Care at Glendale West received any fines or penalties?
Who owns Complete Care at Glendale West?
When was Complete Care at Glendale West last inspected?
What quality measures are tracked for Complete Care at Glendale West?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.