Complete Care at Kensington
1810 Kensington Dr, Waukesha, WI 53188
Complete Care at Kensington is a nursing home in Waukesha, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (262) 548-1400
- Last standard health inspection
- April 29, 2026 (6 months ago)
- Certified beds
- 150
- Residents per day, on average
- 67.2
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Waukesha Healthcare and Rehabilitation Center LLC
- Chain
- Complete Care
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (32 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
4 citations
Health inspection on April 29, 2026
CMS lists this as a standard inspection.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0851 3 times since 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0686 3 times since 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 22, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0880 4 times since 2024.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
1 citation
Health inspection on February 23, 2026
CMS lists this as a complaint inspection.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 20, 2026.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Name
CMS lists a new name for this home. It was KENSINGTON CARE AND REHAB CENTER.
9 citations
Health inspection on May 21, 2025
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 12, 2025.
Citation F0628. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on June 12, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 12, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on June 12, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 12, 2025.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on June 12, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 12, 2025.
CMS has cited this home for F0690 2 times since 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 12, 2025.
CMS has cited this home for F0759 2 times since 2024.
Citation F0851. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on June 12, 2025.
2 citations
Fire safety inspection on May 21, 2025
CMS lists this as a standard inspection.
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on June 12, 2025.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on June 12, 2025.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 31, 2024
Fine
CMS changed the fine from January 30, 2024 from $102,510 to $66,632.
CMS update of March 28, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
11 citations
Health inspection on February 22, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 15, 2024.
Citation F0686. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 15, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on March 15, 2024.
CMS has cited this home for F0558 2 times since 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 15, 2024.
CMS has cited this home for F0689 2 times since 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on March 15, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 15, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 15, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on March 15, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 15, 2024.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on March 15, 2024.
Citation F0851. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on March 15, 2024.
1 citation
Fire safety inspection on February 22, 2024
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on March 13, 2024.
CMS update of January 31, 2024
Fine
CMS changed the fine from November 10, 2022 from $15,000 to $9,750.
5 citations
Health inspection on January 30, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 15, 2024.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 31, 2024.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on February 13, 2024.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on February 13, 2024.
Citation F0949. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on February 13, 2024.
Fine
January 30, 2024 (2 years ago)
CMS fine of $66,632 on January 30, 2024.
2 citations
Health inspection on October 6, 2023
CMS lists this as a complaint inspection.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on October 17, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on October 17, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- PEACE CAPITAL LLC5% or greater direct ownership interest · 100% · since 05/03/2024
- STEIN, SHALOMIndirect ownership interest · not applicable · since 08/01/2017
- CULP, KARENOperational/managerial control · not applicable · since 02/03/2020
- HELLMAN, YOSEFOperational/managerial control · not applicable · since 08/01/2017
- KLEKAMP, CHRISTINEOperational/managerial control · not applicable · since 04/13/2020
- REED, RACHELOperational/managerial control · not applicable · since 11/20/2022
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 07/28/2020
Questions
When was Complete Care at Kensington last inspected?
CMS lists April 29, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Complete Care at Kensington have?
CMS lists 32 health citations since October 6, 2023. CMS also calls these deficiencies.
Has Complete Care at Kensington been fined?
CMS lists 1 fine in the past three years, $66,632 in total.
What is the CMS star rating of Complete Care at Kensington?
Its CMS overall star rating is 1 of 5.
Is Complete Care at Kensington a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.