Complete Care at Hales Corners
9449 W. Forest Home Ave., Hales Corners, WI 53130 · For profit - Corporation · 62 certified beds · (414) 529-6888 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,934 in federal fines (most recent 2024-03-27)
- nursing-staff turnover (65%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.7% | 16.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.8% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 2.1% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 2.9% | 2.7% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.0% | 5.7% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.0% | 18.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 9.3% | 16.9% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.1% | 24.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 15.8% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.2% | 82.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.2% | 23.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.3% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.00 | 1.66 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.56 | 2.29 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 224 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 144 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.1%CMS range 50.6–61.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.9%CMS range 9.6–17.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 49.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.8–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 55.6 residents a day — about 90% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.73 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.29 hrs/resident/day on weekends vs 4.78 on weekdays — 10% thinner on weekends. RN hours go from 0.91 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2024-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 2 (R43 and R19) of 3 residents reviewed for pressure injuries. *R43 was admitted to the facility with an Unstageable pressure injury to the right elbow that required antibiotics for a wound infection and developed pressure injuries to the left heel and right Achilles. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound. *R19 was admitted to the facility with a Stage 3 pressure injury to the right outer ankle. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound. Findings include: The facility policy and procedure entitled Pressure Ulcer Management dated 11/29/6 states: Procedure: . 2. The licensed nurse further assesses all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, and facility document review, the facility failed to maintain a resident's dignity by failing to close the door and curtains while providing care for one resident (Resident (R) 3) out of total sample of six residents. This failure had the potential to compromise the resident's dignity. Findings include: Review of R3's comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25, located in the MDS tab of the EMR, revealed R3 was admitted to the facility on [DATE] with diagnoses that included dementia and age-related osteoporosis. R3 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R3 had severe cognitive impairment. On 02/19/26 at 5:30 AM, observation from the hallway revealed Certified Nursing Assistant (CNA) 1 at R3's bedside performing cares. R3 was undressed with curtains open and door open, visible to the hallway. During an interview on 02/19/26 at 5:37 AM, CNA1 admitted she had failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to document a thorough investigation into the allegation of neglect for one resident (Resident (R) 4) and did not evaluate a Certified Nursing Assistant's (CNA's) history of concerning interactions with residents during an investigation of neglect reported by R2 for two of three facility reported incidents reviewed for abuse or neglect. This failure created the potential for similar incidents to recur.Findings include: 1. Review of R4's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R4 was admitted to the facility on [DATE] and had diagnoses including myocardial infarction, congestive heart failure, and cellulitis. Review of the facility's Misconduct Incident Report, provided by the facility and dated 01/21/26, revealed that on 01/19/26, R4's family member (FM) 5 expressed concern about swelling in R4's feet. Nursing staff assessed her condition, noted swelling in both legs and feet, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not allow residents and/or residents representative to obtain a copy of personal and medical records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request for 1 of 1 (R1) resident reviewed.R1's daughter/POA (power of attorney) requested copies of his medical record were not provided.Findings include:R1 admitted to the facility on [DATE] and had diagnoses that included right femur fracture, right radius fracture, right ulnar fracture, acute posthemorrhagic anemia, chronic diastolic congestive heart failure, hypertensive heart disease, dementia, obstructive sleep apnea, hypokalemia, gastroesophageal reflux disease, insomnia, benign prostatic hyperplasia, presence of prosthetic heart valve, history of malignant neoplasm of prostate, cardiac pacemaker, pyelonephritis, metabolic encephalopathy, intervertebral disc degeneration lumbar region, polyneuropathy, spinal stenosis,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R2) of 3 Residents.On 7/21/25 R2's left facial mass was observed with organism maggot looking like moving all over its surface. R2 was transferred to the hospital and hospitalized until 7/25/25. Hospital course includes documentation of chronic left facial mass for the past 2 years which apparently the patient has refused treatment which has grown bigger in size fungating with maggots' infestation. The facility did not investigate R2's maggot infestation, did not monitor the maggots and did not develop a plan of care for maggots and R2's refusals.Findings include:R2 was originally admitted to the facility on [DATE] with diagnoses which includes dementia (loss of cognitive function that interferes with a person's daily life & activities), hypertension (high blood pressure), depression, and squamous cell carcinoma of skin. R2 has an activated power of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not maintain an effective pest control for 1 (R2) of 1 resident.On 7/21/25 R2 was identified with having maggot looking like organisms moving all over R2's left facial mass. The facility did not increase their pest control services to treat R2's room for flies. Findings include:The facility's policy titled, Pest Control Program and dated 5/25 under policy documents It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Under policy explanation and compliance guidelines documents 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated.R2 was originally admitted to the facility on [DATE] with diagnoses which includes dementia (loss of cognitive function that interferes with a person's daily life & activities), hypertension (high blood pressure), depression, and squamous cell…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R20) of 2 residents reviewed for investigations regarding allegations of abuse, that lawn enforcement was notified of potential allegations of abuse. On 4/20/25, R20 told RN (registered nurse) Supervisor-D that CNA (certified nursing assistant)-C pushed R20. The facility immediately placed CNA-C on suspension pending the investigation. The investigation was conducted immediately. The facility failed to notify the police of this allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation policy dated 5/28/25 documents: . VII.Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) R19 was hospitalized on [DATE] with a change in condition and returned to the facility on 3/11/25. After R19 was readmitted to the facility, on 3/11/25, R19 was sent back to the hospital for increased pain in her knee. R19 was readmitted to the facility on [DATE]. On 6/17/25 Surveyor requested the transfer and bed hold notice for R19 hospitalization from 3/5/25 to 3/11/25 and from 3/11/25 to 3/12/25. On 6/17/25 at 1:52 p.m. NHA (Nursing Home Administrator)-A explained to Surveyor that the facility has not been doing the transfer and bed hold notices since they switch over to a new EMR (electronic medical record) in January 2025. NHA-A stated the nurses had been doing the notices when the facility had the old EMR system. No additional information was provided. Based on interview and record review, the facility did not ensure 3 (R49, R19, and R43) of 3 resident's reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R1) of 12 sampled residents reviewed for a change of condition. *R1 was diagnosed with a wound on 03/09/2025. The facility did not ensure that at the time of R1's initial assessment and diagnosis of a skin wound, a clinician assessed the wound to determine the wound type. The facility did not document the evaluation, assessment, treatment and treatment outcomes for R1's wound. The facility did not have a skin care plan or risk for pressure injuries care plan for R1 until the discovery of R1's wound. R1's Orthopedic specialist was not consulted in the change of condition regarding the orthopedic hardware protruding from R1's skin. The facility did not specify the location of R1's wound on the facility's wound evaluation assessments until 03/26/2025. Findings include: 1.) R1 was admitted to the facility on [DATE] following a hospital stay…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 2 (R19 and R35) of 2 residents received the necessary services for acceptable nutrition. * R19 had a 7.65% weight loss in one month. The weight loss was not communicated to the physician and dietician. A comprehensive assessment was not completed regarding the weight loss. The care plan was not reviewed and updated regarding the weight loss. Interventions were not implemented for R19's weight loss. * R35 required supervision during meals and was observed on two occasions not to receive assistance with meals as per care plan. Findings include: The facility's Weight Monitoring policy dated 5/28/25 documents: 4. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) The following formula may be used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 3 (R5, R9 and R250) of 3 residents residing at the facility whom receive a puree diet. *Cook-C was observed not following a recipe for preparing texture and modified consistency food for puree diets. Findings include: The facility's policy titled, Pureed Food Preparation dated 5/28/25 documents: Each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor and appearance. The policy does not document that the facility must follow a recipe to prepare pureed food. On 06/16/25 at 9:43 AM, Cook-C was observed preparing grilled cheese for residents receiving pureed food. Cook-C was observed putting 8 pieces of untoasted white bread, and 3.5 cups of liquid cheese prepared from a powder mix into the blender. The blended mix was put in a metal cooking container and placed in the oven to keep warm. [NAME] -C was asked for the recipe used for the pureed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2025-06-18 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide special assistive eating equipment for 1 (R250) of 1 sampled resident reviewed for assistive eating devices. R250's emergency contact and family member (FM)-E, informed Surveyor that R250 does not always get the adaptive equipment placed on R250's meal tray so that R250 can eat independently. Surveyor observed R250's meal tray ticket and noted that the adaptive equipment listed on the meal tray ticket did not match what was provided on R250's meal tray. Findings include: The facility policy dated 5/28/25 titled, Meal Supervision and Assistance, documents, in part: Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Ensure that the necessary non-food items (i.e., silverware, napkin, special devices, straw, etc.) are on the tray; especially assistive and adaptive devices. Report or replace missing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-27 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not thoroughly investigate an allegation of misappropriation affecting 1 (R147) of 1 residents in a Facility Reported Incident that was reviewed. R147 reported a missing wallet. The facility administration did not interview residents in the facility at the time of the report to determine if any other residents were affected by potential theft. Findings include: On 11/15/2023, R147 reported to Social Worker (SW)-C their wallet was missing. The wallet contained money, credit cards, insurance cards and driver's license. SW-C initiated an investigation by interviewing R147's family members who were aware of the missing wallet to determine when the wallet was last seen and to verify no family member had taken the wallet out of the facility. It was determined through those interviews that the wallet was last seen on Friday evening, 11/10/2023. SW-C interviewed all staff members that had worked at the facility 11/10/2023-11/15/2023 with no staff aware of R147's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-01-12 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and record review, the facility failed to ensure the facility developed and followed the menus and that the menus met the nutritional needs of the residents. This failure placed all 38 facility residents at risk of nutritional problems and dissatisfaction with their meals. Findings include: Review of the facility's 01/09/23 to 01/13/23 weekly menu, provided on paper by Dietary Manager (DM) E, revealed it did not include extensions for therapeutic diets or portion sizes. The weekly menu documented the 01/11/23 lunch menu for the following for Wednesday: -Chicken noodle soup or yogurt and fruit plate -Corndog -Potato chips -Peppermint cake There were no alternatives listed for therapeutic diets, such as Mechanical Soft, and there were no portion sizes listed. Observation in the kitchen during lunch tray line on 01/11/23 at 12:01 PM revealed, [NAME] L served: -Four ounces chicken noodle soup or a pre-prepared fruit salad -One corn dog -One small bag of potato chips -One approximately 4 inches (in) by 4 in piece of cake. Additionally, [NAME] L served the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-01-12 · tag F0886 — failed to test for COVID-19 as required — widespreadPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to implement staff COVID-19 testing in the presence of a COVID-19 outbreak in the facility. This failure affected all 134 who worked in the facility and all 38 residents. This failure had the potential to contribute to spread of COVID-19 within the facility. Findings include: Review of the facility's policy titled, Testing for COVID-19 in Residents and Employees dated 09/28/22, documented All employees will be tested for CO\/ID-19 if there is an outbreak, defined as one case. Review of the CDC's COVID-19 Data Tracker website, accessed on 01/10/23 at https://covid.cdc.gov/covid-data-tracker/#datatracker-home, the facility's community transmission level was high. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 01/11/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure that one resident (Resident (R) 28) of three residents reviewed for accidents received adequate interventions to prevent the resident from sustaining continued falls. Findings include: Review of the facility's undated policy titled, Falls Prevention, provided by facility revealed, Each resident shall be assessed for risk of falls upon admission, quarterly, annually and as a change of condition warrants .Upon determination, per assessment and observation, that a risk for falls is present, facility staff will initiate any and/or all, but not limited to, the following interventions as appropriate: A. An individualized care plan will be developed to meet any resident's safety needs. B. A speech, Physical and Occupational Therapy Screen will be performed to determine limitations and needs. C. Adaptive equipment will be provided as appropriate to meet safety needs. D. Interventions specific to the resident's need will be initiated including but not inclusive to low beds, bed sensors, floor mats,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-01-12 · tag F0888 — widespreadEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and review of the facility's policy, the facility failed to develop and implement their policy for additional infection control precautions for unvaccinated staff. These failures had the potential to reduce efforts to mitigate COVID-19 transmission, consequently placing all staff and all current clients receiving care at this facility at risk of exposure to COVID-19. Findings include: Review of the CDC's COVID-19 Data Tracker website, accessed on 01/10/23 at https://covid.cdc.gov/covid-data-tracker/#datatracker-home, the facility's community transmission level was high. Review of the facility's policy titled COVID-19 Mandatory Vaccination Program, updated 06/2021 documented Employees that have been granted an exemption will adhere to additional precautions, such as source control, testing, NIOSH-approved N-95 masks, which are intended to mitigate the spread of COVID-19. These precautions may be modified in response to state and local COVID-19 positivity and transmission rates. During an interview and observation on 01/11/23 at 2:26 PM, Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$17,934 in federal fines across 1 penalty.
- $17,934 — penalty dated 2024-03-27
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 84; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PC HALES CORNERS OPCO HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/28/2025 |
| PC HALES CORNERS TOPCO OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2025 |
| PEACE CAPITAL HOLDINGS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/28/2025 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/28/2025 |
| DES CAPITAL LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 05/28/2025 |
| JRK INVESTMENTS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 05/28/2025 |
| KLUGMAN, JACOB | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 05/28/2025 |
| STEIN, SHALOM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 05/28/2025 |
| STERNBUCH, DANIEL | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| HELLMAN, YOSEF | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/28/2025 |
| BIELINSKI, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| CHANG, STEVE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| JACOBS, SARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| PONCE, MARIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| HALES CORNERS PROPCO LLC | Organization | ADP OF THE SNF | — | since 05/29/2025 |
| PC HALES CORNERS PROPCO HOLDCO LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| PC HALES CORNERS TOPCO PROPCO LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| WEISSMAN, MALKA | Individual | ADP OF THE SNF | — | since 05/28/2025 |
CMS files one row per role, so the 33 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $527K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525596. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.