01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-29 | 5 | 2026-04-29 | 0 |
| Cycle 2 | 2025-05-21 | 9 | 2025-05-21 | 2 |
| Cycle 3 | 2024-02-22 | 18 | 2024-02-22 | 1 |
CMS CCN 5252422026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Kensington
1810 Kensington Dr · Waukesha, WI 53188 · Waukesha County
Certified beds150CMS provider file
Recent citation rows35current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
35 rows in the current release
3 rows carry G–L scope/severity codes; 2 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-29 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-05-222026-04-29 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-05-222026-04-29 · HEALTHF0851Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2026-05-222026-04-29 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-222026-02-23 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-03-20 · complaint2025-05-21 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0687Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0851Severity C · widespread; potential for minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-21 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-122024-02-22 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2024-03-132024-02-22 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-03-15 · complaint2024-02-22 · HEALTHF0686Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-03-152024-02-22 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-03-15 · complaint2024-02-22 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-03-152024-02-22 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2024-03-152024-02-22 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-03-152024-02-22 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-03-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-01-30 | Fine | $66,632 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PEACE CAPITAL LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 05/03/2024
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 08/01/2017
- STEIN, SHALOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/01/2017
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/01/2017
- CULP, KARENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/03/2020
- HELLMAN, YOSEFIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2017
- KLEKAMP, CHRISTINEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/13/2020
- REED, RACHELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/20/2022
- SIDHU, SARFRAZIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/28/2020
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 08/01/2017
- DES CAPITAL LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- JRK INVESTMENTS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- PEACE CAPITAL HOLDINGS II LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- SMS 2021 TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- WAKESHA PROPCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- WI 6 PROPCO HOLDCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- WI 6 PROPCO TOPCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2017
- CULP, KARENIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/03/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.53per resident day
RN hours0.58per resident day
Weekend nurse hours3.14per resident day
Staff turnover55.8%CMS reported field
06 / LOCAL RECORDS
Open the Waukesha ledger →