Complete Care at Kensington

Name: Complete Care at Kensington
Address: 1810 KENSINGTON DR, Waukesha, WI, 53188, US
Telephone: 2625481400

1810 Kensington Dr, Waukesha, WI 53188 · Waukesha County · 150 certified beds · avg 69 residents/day · certified since Jun 17, 1971

Part of chain: COMPLETE CARE (85 facilities, chain avg rating 3.1★)

2/5

Health inspection rating (on-site)

Serious findings on record

$66,632

Fines, last 3 years

3.00

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jan 30, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 15, 2024 (Past Non-Compliance)

▲ Immediate jeopardy, one-off · Jan 30, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Corrected: Jan 31, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · May 21, 2025 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 12, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (32)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 29, 2026	F · Potential for harm, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Apr 29, 2026	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Apr 29, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 29, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 23, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
May 21, 2025	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
May 21, 2025	E · Potential for harm, repeated	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
May 21, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 21, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 21, 2025	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
May 21, 2025	D · Potential for harm, one-off	The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
May 21, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
May 21, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 21, 2025	C · Minimal risk, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Feb 22, 2024	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 22, 2024	E · Potential for harm, repeated	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Feb 22, 2024	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Feb 22, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 22, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Feb 22, 2024	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 22, 2024	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 22, 2024	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Feb 22, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 22, 2024	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Feb 22, 2024	C · Minimal risk, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Jan 30, 2024	▲ J · Immediate jeopardy, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 30, 2024	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 30, 2024	F · Potential for harm, facility-wide	The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint
Jan 30, 2024	F · Potential for harm, facility-wide	The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. · from a complaint
Jan 30, 2024	F · Potential for harm, facility-wide	The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint
Oct 6, 2023	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Oct 6, 2023	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (9 → 4).

Year	Citations	Serious (G–L)	Worst severity that year
2023	2	0	E
2024	16	2	J ▲
2025	9	1	G ▲
2026	5	0	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $66,632.

Date	Type	Amount / length
Jan 30, 2024	Fine	$66,632

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Wisconsin avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.00	4.29	3.95	bottom 4% in Wisconsin; bottom 14% in the U.S.
Registered Nurse hours	0.49	1.01	0.69	bottom 5% in Wisconsin; bottom 36% in the U.S.
Weekend total nurse staffing	2.67	3.84	3.50	bottom 6% in Wisconsin; bottom 15% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.36	0.68	0.48	bottom 11% in Wisconsin; bottom 44% in the U.S.
Total nursing staff turnover (%)	55.8	46.9	45.8	bottom 26% in Wisconsin; bottom 23% in the U.S.
RN turnover (%)	50.0	39.7	42.9	bottom 36% in Wisconsin; bottom 39% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.53, RN 0.58, weekend 3.14. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Peace Capital LLC	Organization	5% or Greater Direct Ownership Interest	100%	05/03/2024
Stein, Shalom	Individual	Indirect Ownership Interest	NOT APPLICABLE	08/01/2017
Culp, Karen	Individual	Operational/Managerial Control	NOT APPLICABLE	02/03/2020
Culp, Karen	Individual	ADP of the SNF	NOT APPLICABLE	02/03/2020
Des Capital LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2017
Hellman, Yosef	Individual	Operational/Managerial Control	NOT APPLICABLE	08/01/2017
Hellman, Yosef	Individual	ADP of the SNF	NOT APPLICABLE	08/01/2017
JRK Investments LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2017
Klekamp, Christine	Individual	Operational/Managerial Control	NOT APPLICABLE	04/13/2020
Klekamp, Christine	Individual	ADP of the SNF	NOT APPLICABLE	04/13/2020
Klugman, Jacob	Individual	ADP of the SNF	NOT APPLICABLE	08/01/2017
Peace Capital Holdings II LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2017
Reed, Rachel	Individual	Operational/Managerial Control	NOT APPLICABLE	11/20/2022
Reed, Rachel	Individual	ADP of the SNF	NOT APPLICABLE	11/20/2022
Sidhu, Sarfraz	Individual	Operational/Managerial Control	NOT APPLICABLE	07/28/2020
Sidhu, Sarfraz	Individual	ADP of the SNF	NOT APPLICABLE	08/01/2017
SMS 2021 Trust	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2017
Stein, Shalom	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/01/2017
Stein, Shalom	Individual	Corporate Officer	NOT APPLICABLE	08/01/2017
Stein, Shalom	Individual	Trustee of the SNF	NOT APPLICABLE	08/01/2017

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Avina of Pewaukee	1.2 mi	Waukesha, WI	★☆☆☆☆	1/5
Lindengrove Waukesha	1.4 mi	Waukesha, WI	★☆☆☆☆	1/5
Aria of Waukesha	2.5 mi	Waukesha, WI	★☆☆☆☆	2/5
Complete Care at Care Age	5.8 mi	Brookfield, WI	★☆☆☆☆	1/5
Aria of Brookfield	6.3 mi	Brookfield, WI	★☆☆☆☆	1/5	abuse
Franciscan Woods	6.5 mi	Brookfield, WI	★☆☆☆☆	1/5
Lindengrove New Berlin	8.7 mi	New Berlin, WI	★☆☆☆☆	1/5
Congregational Home, INC.	10.0 mi	Brookfield, WI	★★★★☆	3/5
Tudor Oaks Health Center	10.0 mi	Muskego, WI	★★☆☆☆	2/5
Muskego Health and Rehabilitation Center	10.0 mi	Muskego, WI	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Waukesha →

Facility data as of CMS processing date 2026-08-01. CCN 525242.

The Care File

Visit checklist — Complete Care at Kensington

1810 Kensington Dr, Waukesha, WI 53188 · 2625481400

Health inspection rating 2/5 · CMS overall 1/5· Fines (3y): $66,632

Most serious findings on record:

▲ Jan 30, 2024 (F-0684, Immediate jeopardy, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
▲ Jan 30, 2024 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ May 21, 2025 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 525242 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)