Report
TheVardellReport
Complete Care at Kensington
Skilled nursing facility and nursing facility
1810 Kensington Dr
Waukesha, WI 53188
Report
← Complete Care at Kensington, free profile
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The Vardell Report.Complete Care at Kensington
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Waukesha, WI
- Record Period
- 2023–2026
- Source Documents
- 8
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 6 inspections from October 2023 to April 2026, state surveyors documented 32 findings at Complete Care at Kensington; 32 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 6
- 2023–2026, standard and complaint
- Findings
- 32
- Deficiencies cited by state inspectors
- Corrected
- 32
- Of 32 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 2 | 0 |
| 2024 | 2 | 16 | 2 |
| 2025 | 1 | 9 | 1 |
| 2026 | 2 | 5 | 0 |
What the Record Shows
- 32 of 32 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $66,632, its payment not published.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, April 29, 2026, recorded 4 findings (most serious: Level F).
What to Ask About
- Infection Control, Cited in Four Inspections
- Pressure Injury Care, Cited in Three Inspections
- Citation F851, Cited in Three Inspections
- Needs and Preferences, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Continence and Catheter Care, Cited in Two Inspections
- Medication Error Rate, Cited in Two Inspections
Report at a Glance
- Facility
- Complete Care at Kensington
- Address
- 1810 Kensington Dr, Waukesha, WI 53188
- CMS Certification Number
- 525242
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 150
- Ownership
- For profit - Limited Liability company
- Record Window
- October 6, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
4 findings
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected May 22, 2026
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 22, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 22, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 22, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 20, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
9 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jun 12, 2025
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Jun 12, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 12, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 12, 2025
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 12, 2025
- F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jun 12, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jun 12, 2025
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 12, 2025
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level CPotential for minimal harmCorrected Jun 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
11 findings
The same visit included a complaint investigation.
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Mar 15, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level CPotential for minimal harmCorrected Mar 15, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
5 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jan 15, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jan 31, 2024
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Feb 13, 2024
- F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Feb 13, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level FNo actual harm, potential for moreCorrected Feb 13, 2024
Enforcement Action
Civil money penalty, $66,632 imposed January 30, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of January 30, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
2 findings
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Oct 17, 2023
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 17, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Infection Control, Cited in Four Inspections
Inspectors cited F880 in February 2024, May 2025, February 2026 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F880 across all 6 inspections, oldest to newest - 2
Pressure Injury Care, Cited in Three Inspections
Inspectors cited F686 in February 2024, May 2025 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F686 across all 6 inspections, oldest to newest - 3
Citation F851, Cited in Three Inspections
Inspectors cited F851 in February 2024, May 2025 and April 2026. The agency describes it this way: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F851 across all 6 inspections, oldest to newest - 4
Needs and Preferences, Cited in Two Inspections
Inspectors cited F558 in October 2023 and February 2024. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F558 across all 6 inspections, oldest to newest - 5
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in January 2024 and February 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F689 across all 6 inspections, oldest to newest - 6
Continence and Catheter Care, Cited in Two Inspections
Inspectors cited F690 in February 2024 and May 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F690 across all 6 inspections, oldest to newest - 7
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in February 2024 and May 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252626F759 across all 6 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level F.
- 02
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in three inspections, most seriously at level G.
- 03
What changed after F851 was cited, and how do you check it now?
Citation F851: cited in three inspections, most seriously at level F.
- 04
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in two inspections, most seriously at level D.
- 05
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level J.
- 06
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
- 07
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level D.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 09
What led to the 2024 fine, and has it been paid?
A $66,632 civil money penalty was imposed January 30, 2024. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Oct 6, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jan 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Feb 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection May 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Feb 23, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Apr 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 525242
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowOctober 6, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before October 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.