Complete Care at Kensington
Open-data reference.
Complete Care at Kensington is a for profit - limited liability company facility in WAUKESHA, WI with 150 certified beds and a 1-star overall CMS rating. The facility has 39 deficiency records on file. Total penalties: $67K.
1810 KENSINGTON DR, WAUKESHA, WI 53188
Phone: 2625481400
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525242
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 150
- Residents
- 66
- In Hospital
- No
- County
- Waukesha
- Last Inspection
- May 21, 2025
Staffing Data
- RN Hours
- 0.57 (nat'l avg: 0.68)
- LPN Hours
- 1.13
- CNA Hours
- 1.95
- Total Nursing Hours
- 3.65 (nat'l avg: 3.89)
- PT Hours
- 0.03
- Nursing Turnover
- 55.3%
- RN Turnover
- 63.6%
What the CMS Record Reveals About Complete Care at Kensington
Complete Care at Kensington operates 150 certified beds in WAUKESHA, WI with approximately 66 residents currently in care, and carries a CMS overall rating of 1 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 (1★), and quality measures (3★). 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 39 deficiency records from recent surveys, of which 3 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 $67K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.65 total nursing hours per resident day (national average 3.89), with RN coverage at 0.57 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 Kensington 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 55.3%, above the level where continuity of care typically begins to suffer. 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 (39 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 12, 2025
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Category: Administration Deficiencies
Corrected: Jun 12, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jun 12, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 12, 2025
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 12, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 12, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Jun 12, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 12, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 12, 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: Mar 15, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Mar 15, 2024
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Mar 15, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 15, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Category: Administration Deficiencies
Corrected: Mar 15, 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: Mar 15, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Mar 15, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Mar 15, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 15, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 15, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 15, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Feb 13, 2024
Provide training in compliance and ethics.
Category: Administration Deficiencies
Corrected: Feb 13, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Feb 13, 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: Jan 31, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 15, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 17, 2023
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Oct 17, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 1, 2022
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: Dec 2, 2022
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 2, 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: Dec 2, 2022
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Dec 2, 2022
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: Dec 2, 2022
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 2, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 2, 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: Dec 2, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 2, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 2, 2022
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Nov 30, 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 | 9.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 15.9% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.7% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 9.1% | 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 | 1.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 98.1% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 13.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 8.3% | 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 | 94.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 24.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 19.2% | Yes |
Penalty History 1 penalties totaling $67K
| Date | Type | Amount |
|---|---|---|
| Jan 30, 2024 | Fine | $67K |
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Frequently Asked Questions
What is the overall CMS rating for Complete Care at Kensington?
What are the staffing levels at Complete Care at Kensington?
How many beds does Complete Care at Kensington have?
Does Complete Care at Kensington have any deficiencies on record?
Has Complete Care at Kensington received any fines or penalties?
Who owns Complete Care at Kensington?
When was Complete Care at Kensington last inspected?
What quality measures are tracked for Complete Care at Kensington?
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.