D
Lindengrove Waukesha
39/100 score
0.93 hrs RN staffing
14 deficiencies
Complete Care at Kensington
1810 KENSINGTON DR, WAUKESHA, WI 53188
Operator
PEACE CAPITAL · 11 facilities
- Provider number (CCN)
- 525242
- Certification
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified beds
- 150
- Phone
- (262) 548-1400
- CMS data as of
- August 1, 2026
D
●
stable
Staffing 0% · Deficiencies 0% over tracking period
What the records show
CMS rates Complete Care at Kensington 1 out of 5 stars overall, with 2 of 5 for health inspections, 1 of 5 for staffing, 3 of 5 for quality measures. Federal inspectors cited 32 health deficiencies across the last three survey cycles, most recently surveyed in 2026, 3 at actual-harm level or higher. CMS enforcement records list 1 fine totalling $66,632.
Facility Assessment
Inspectors recorded 3 citations at the actual-harm level or worse in the last three survey cycles.
Reviews, Ratings and Official Records
This page reviews Complete Care at Kensington using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.
At or above the 2024 benchmark — review the inspection and enforcement records below for the safety history behind the grade.
Ratings and Grade Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.58 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
32
Outstanding
0
Actual harm or worse (G–L)
3
|
|
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
|
Overall: ★☆☆☆☆ (1/5)
Health inspection: ★★☆☆☆ (2/5)
Quality: ★★★☆☆ (3/5)
Staffing: ★☆☆☆☆ (1/5)
|
|
NursingHomeGrade Score
|
49/100 |
Loaded into NursingHomeGrade on September 5, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.
Staffing Compared With State and National Levels
| This facility | 0.58 hrs |
|---|---|
| WI median | 0.93 hrs |
| National average | 0.69 hrs |
Registered nurse turnover: 50.0% · Total nursing staff turnover: 55.8%
Staffing figures are the values CMS published in its file processed August 1, 2026, drawn from payroll-based journal reporting.
Inspection Records Covered
- Most recent standard health survey: April 29, 2026.
- Citations shown below span 3 recorded inspection cycles.
- Survey dates on file range from October 6, 2023 to April 29, 2026.
Source records: CMS Care Compare profile for provider 525242 ↗ · the federal files we load and when.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
2 immediate jeopardy, 1 actual harm issues found among 32 total deficiencies. 32 corrected.
Most recent inspection (April 29, 2026)
F
Potential harm — widespread
F0851
Status: Corrected
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2026
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2026
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 20, 2026
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2026
D
Potential harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2026
Inspection cycle 2 (May 21, 2025)
C
No harm — widespread
F0851
Status: Corrected
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
D
Potential harm — isolated
F0610
Status: Corrected
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
D
Potential harm — isolated
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
G
Actual harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
D
Potential harm — isolated
F0687
Status: Corrected
Provide appropriate foot care.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
E
Potential harm — pattern
F0628
Status: Corrected
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 12, 2025
Inspection cycle 3 (February 22, 2024)
C
No harm — widespread
F0851
Status: Corrected
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
F
Potential harm — widespread
F0868
Status: Corrected
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2024
F
Potential harm — widespread
F0946
Status: Corrected
Provide training in compliance and ethics.
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2024
F
Potential harm — widespread
F0949
Status: Corrected
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2024
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0881
Status: Corrected
Implement a program that monitors antibiotic use.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
E
Potential harm — pattern
F0804
Status: Corrected
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2023
D
Potential harm — isolated
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
E
Potential harm — pattern
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0692
Status: Corrected
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
J
Immediate jeopardy — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected January 15, 2024
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2024
D
Potential harm — isolated
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2024
D
Potential harm — isolated
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2023
Fines and Enforcement Actions
Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.
| Date | Action | Amount or length |
|---|---|---|
| January 30, 2024 | Fine | $66,632 |
1 fine totalling $66,632.
Source: CMS Penalties file (dataset g6vv-u9sr).
Ownership and Contact Information
- Facility name
- Complete Care at Kensington
- Legal business name
- WAUKESHA HEALTHCARE AND REHABILITATION CENTER LLC
- Address
- 1810 KENSINGTON DR, WAUKESHA, WI 53188
- Phone
- (262) 548-1400
- Provider number (CCN)
- 525242
- Ownership type
- For profit - Limited Liability company
- Operator
- PEACE CAPITAL · 11 facilities
- Medicare/Medicaid certified since
- June 17, 1971
- Official record
- CMS Care Compare profile ↗
- Details verified against CMS data dated
- August 1, 2026
The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.
How We Stay Independent
NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.
Learn about our data methodology →Nearby facilities in WAUKESHA
Compare local nursing homes using the same CMS-backed grading method.
D
Aria of Waukesha
37/100 score
0.69 hrs RN staffing
12 deficiencies
F
Avina of Pewaukee
28/100 score
0.51 hrs RN staffing
19 deficiencies
D
Complete Care at Care Age
37/100 score
0.62 hrs RN staffing
12 deficiencies
F
Aria of Brookfield
0/100 score
0.45 hrs RN staffing
23 deficiencies
Sources and Methodology
- CMS Provider Information (file processed August 1, 2026) — ratings, staffing, ownership, certification and contact details. Dataset 4pq5-n9py ↗
- CMS Health Deficiencies — inspection citations, scope and severity, correction status. Dataset r5ix-sfxw ↗
- CMS Penalties — fines and payment denials with the dates CMS recorded them. Dataset g6vv-u9sr ↗
- CMS Ownership — owning and managing organisations. Dataset y2hd-n93e ↗
The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.
Need help choosing a facility?
Get free guidance from senior living advisors. We don't earn a fee for these links, and we never take payment from nursing facilities.
Get help finding alternatives ↗ Compare nearby ↗↗ Links open independent third-party sites in a new tab.
Get score alerts for this facility
We'll email you when Complete Care at Kensington's staffing score changes.