Cycle 1
Health 2025-06-18 · Fire 2025-06-18
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Hales Corners, WI
Complete Care at Hales Corners
4-star overall rating with 4-star inspections with $17,934 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
9449 W. Forest Home Ave., Hales Corners, WI
(414) 529-6888
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1996-06-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,891
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.43
Baseline 21.67% · Performance 19.38% · Measure score 4.43 · Achievement 4.42 · Improvement 4.43
Healthcare-associated infections
4.72
Baseline 7.74% · Performance 6.42% · Measure score 4.72 · Achievement 4.72 · Improvement 4.30
Total nurse turnover
5.09
Baseline 49.15% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 2.09
Adjusted total nurse staffing
2.65
Baseline 4.21 hours · Performance 3.83 hours · Measure score 2.65 · Achievement 2.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.93% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 216 · Observed rate 12.04% · Lower 95% interval 9.56% |
| Discharge to community | 56.1% |
50.57%
5.5 pts better
|
Better than the National Rate · Eligible stays 224 · Observed rate 54.91% · Lower 95% interval 50.57% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 167 · Denominator 167 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 167 |
| Discharge self-care score | 42.66% |
53.69%
11 pts worse
|
Numerator 61 · Denominator 143 |
| Discharge mobility score | 41.96% |
50.94%
9 pts worse
|
Numerator 60 · Denominator 143 |
| Pressure ulcers or injuries, new or worsened | 2.4% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 167 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 4.05% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 13.99% |
8.2%
5.8 pts better
|
Numerator 20 · Denominator 143 |
| Staff flu vaccination coverage | 66.47% |
42%
24.5 pts better
|
Numerator 111 · Denominator 167 |
| Discharge function score | 44.06% |
56.45%
12.4 pts worse
|
Numerator 63 · Denominator 143 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 113 · Denominator 113 |
| Resident COVID-19 vaccinations up to date | 32.94% |
25.2%
7.7 pts better
|
Numerator 28 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
95.7%
2.9 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.9% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.2%
0.3 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.3% · Q3 5.9% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
5.0%
3.4 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 3.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
4.9%
3 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 15.6% · Q3 3.8% · Q4 3.8% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
16.6%
7.6 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 5.9% · Q3 11.1% · Q4 7.4% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.7%
16.7 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.7% |
21.1%
3.6 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
17.3%
2.8 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 21.9% · Q3 13.0% · Q4 0.0% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.3%
0.9 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 2.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
3.0%
0.7 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 6.1% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
25.5%
0.3 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 28.7% · Q3 31.8% · Q4 25.4% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.5%
2.2 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 11.1% · Q3 12.4% · Q4 0.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
86.8%
10.1 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 90.1% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
15.0%
0.5 pts better
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 12.2% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
82.2%
10 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
22.7%
2.3 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 16.3% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-27 · Fire 2024-03-27
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-18
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-06-18
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-06-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-14
F · Potential for more than minimal harm
2025-06-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-06-18
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-06-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-08
E · Potential for more than minimal harm
2025-06-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-08
E · Potential for more than minimal harm
2025-06-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-08
C · Minimal harm
2025-06-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-08
F · Potential for more than minimal harm
2024-03-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-03-27
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-04-25
F · Potential for more than minimal harm
2024-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-04
E · Potential for more than minimal harm
2024-03-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-04-22
F · Potential for more than minimal harm
2023-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-11
F · Potential for more than minimal harm
2023-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-01-11
E · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-11
E · Potential for more than minimal harm
2023-01-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-12-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-06-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-18
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-18
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-07-07
G · Actual harm
2024-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-25
F · Potential for more than minimal harm
2023-01-12
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-01-13
D · Potential for more than minimal harm
2023-01-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-13
C · Minimal harm
2023-01-12
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-01-13
Penalties and ownership
What sits behind the stars
$17,934
2024-03-27
Fine
Fine · fine $17,934
Fine
Ownership
Pc Hales Corners Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bielinski, Renee
Operational/Managerial Control · Individual
Chang, Steve
Operational/Managerial Control · Individual
Helman, Yosef
Operational/Managerial Control · Individual
Jacobs, Sara
Operational/Managerial Control · Individual
Pc Hales Corners Topco Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Ponce, Maria
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Director · Individual
Sternbuch, Daniel
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#2
Greendale Park Nursing and Rehab
Greendale, WI
1-star overall rating with 1-star inspections with $271,160 in total fines with 19 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Maplewood Center
West Allis, WI
1-star overall rating with 1-star inspections with $508,068 in total fines with 26 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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