F

Complete Care at Kensington

1810 KENSINGTON DR, WAUKESHA, WI 53188
Score: 20 / 100

With a score of 20/100, Complete Care At Kensington ranks in the bottom tier of Wisconsin nursing facilities, earning an F grade. CMS data highlights significant concerns that prospective residents and families should thoroughly evaluate.

Staffing at Complete Care At Kensington is near the national average, with 3.65 total nursing hours per resident per day (national average: 3.8 hours).

Recent CMS inspections identified 39 deficiencies at Complete Care At Kensington, including 2 classified as serious — among the most concerning citation levels. The most notable finding involved: provide appropriate pressure ulcer care and prevent new ulcers from developing..

Score Breakdown

Overall CMS Rating 8 / 40 pts
1 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 4 / 20 pts
1 ★ staffing rating
Quality Measures 9 / 15 pts
3 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.65 3.8 Average
Registered Nurses (RN) 0.57 0.7 Below Average
Licensed Practical Nurses (LPN) 1.13 0.7 Above Average
Certified Nursing Assistants (CNA) 1.95 2.4 Below Average
Weekend Total Nursing 3.12 3.8 Below Average
Weekend RN Hours 0.21 0.7 Below Average

🔍 Inspection & Deficiency History

39
Total Deficiencies
May 20, 2025
Most Recent Inspection
⚪ 3 Minor 🟠 34 Moderate 🔴 2 Serious
View recent deficiencies (5 shown)
  • Tag 0686 Severity G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    May 20, 2025 · Quality of Life and Care Deficiencies
  • Tag 0628 Severity E
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    May 20, 2025 · Resident Rights Deficiencies
  • Tag 0880 Severity E
    Provide and implement an infection prevention and control program.
    May 20, 2025 · Infection Control Deficiencies
  • Tag 0609 Severity D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    May 20, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0610 Severity D
    Respond appropriately to all alleged violations.
    May 20, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 5.5% 4.5% Worse
Falls with major injury 1.2% 3.0% Better
On antipsychotic medication 19.2% 14.5% Worse
Urinary tract infections 2.7% 2.5% Average
ADL decline (daily activities) 9.8% 14.0% Better
Excessive weight loss 15.9% 7.5% Worse
New/worsened incontinence 24.8% 45.0% Better

⚠️ Penalties & Fines

1 penalty recorded by CMS

Total fines: $66,632

How This Grade Was Calculated

This facility's grade of F is based on a score of 20 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 1★ → 8 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 1★ → 4 pts (max 20)
  • Quality Measures Rating: 3★ → 9 pts (max 15)
  • Penalty deductions: -5 pts
  • Fine deductions: -6 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
150
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
May 20, 2025
Deficiencies (Cycle 1)
9