Cycle 1
Health 2025-05-21 · Fire 2025-05-21
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Waukesha, WI
Complete Care at Kensington
1-star overall rating with 2-star inspections with $66,632 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1810 Kensington Dr, Waukesha, WI
(262) 548-1400
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1971-06-17
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
0.57
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,441
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.18
Baseline 24.00% · Performance 20.04% · Measure score 5.18 · Achievement 3 · Improvement 5.18
Healthcare-associated infections
3.86
Baseline 6.01% · Performance 6.68% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Total nurse turnover
2.16
Baseline 68.06% · Performance 56.58% · Measure score 2.16 · Achievement 1.74 · Improvement 2.16
Adjusted total nurse staffing
0.70
Baseline 2.64 hours · Performance 3.01 hours · Measure score 0.70 · Achievement 0 · Improvement 0.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 16.05% · Lower 95% interval 8.07% |
| Discharge to community | 47.67% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 36.76% · Lower 95% interval 36.71% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.73% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 40% |
42%
2 pts worse
|
Numerator 36 · Denominator 90 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 9 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
95.7%
2.4 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.1% · Q3 96.8% · Q4 98.3% · 4Q avg 98.1% |
| 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 | 1.2% |
3.2%
2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 0.0% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.1% |
5.0%
4.1 pts worse
|
11.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.9% · Q3 12.7% · Q4 11.3% · 4Q avg 9.1% |
| Percentage of long-stay residents who lose too much weight | 15.9% |
4.9%
11 pts worse
|
5.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 16.9% · Q3 24.1% · Q4 17.0% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
16.6%
8.3 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 9.8% · Q3 6.9% · Q4 5.7% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
16.7%
2.5 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 20.9% · Q3 20.8% · Q4 21.7% · 4Q avg 19.2% · 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 | 13.5% |
21.1%
7.6 pts better
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
17.3%
7.5 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 13.8% · Q3 7.1% · Q4 6.2% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.3% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
3.0%
0.3 pts better
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 1.5% · Q3 1.6% · Q4 1.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
25.5%
0.7 pts better
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 23.9% · Q3 25.2% · Q4 15.6% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.5%
About the same
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.5% · Q3 5.2% · Q4 4.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
86.8%
9.5 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 96.7% · Q3 97.5% · Q4 95.8% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
15.0%
0.2 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 21.4% · Expected 15.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
82.2%
12.4 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
22.7%
1.7 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 32.1% · Expected 31.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-21
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-12
F · Potential for more than minimal harm
2024-02-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-13
Inspection history
Recent health citations
G · Actual harm
2025-05-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-21
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 2025-06-12
D · Potential for more than minimal harm
2025-05-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-21
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-12
C · Minimal harm
2025-05-21
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-06-12
F · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
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 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-15
C · Minimal harm
2024-02-22
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-03-15
J · Immediate jeopardy
2024-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-15
J · Immediate jeopardy
2024-01-30
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 2024-01-31
F · Potential for more than minimal harm
2024-01-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-30
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-30
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-02-13
E · Potential for more than minimal harm
2023-10-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-10-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-17
E · Potential for more than minimal harm
2022-11-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-11-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-11-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-02
C · Minimal harm
2022-11-10
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
$66,632
2024-01-30
Fine
Fine · fine $66,632
Fine
Ownership
Jn Waukesha LLC
5% Or Greater Direct Ownership Interest · Organization
Peace Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Stein, Shalom
5% Or Greater Indirect Ownership Interest · Individual
Smf Waukesha LLC
5% Or Greater Direct Ownership Interest · Organization
Green, Elyokum
5% Or Greater Indirect Ownership Interest · Individual
Waukesha Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Helman, Yosef
5% Or Greater Indirect Ownership Interest · Individual
Silverberg, Nisanel
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Yisrael
5% Or Greater Indirect Ownership Interest · Individual
Neuman, Mark
5% Or Greater Indirect Ownership Interest · Individual
Singer, Meir
5% Or Greater Indirect Ownership Interest · Individual
Silverberg, Nisanel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Avina of Pewaukee
Waukesha, WI
2-star overall rating with 2-star inspections with $95,791 in total fines with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Lindengrove Waukesha
Waukesha, WI
1-star overall rating with 1-star inspections with $39,621 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Aria Of Waukesha
Waukesha, WI
1-star overall rating with 2-star inspections with $26,480 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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