Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Hales Corners during CMS and state inspections, most recent first.
A resident with dementia and age-related osteoporosis, who had severe cognitive impairment, was observed receiving personal care from a CNA while undressed, with the room door and privacy curtains left open, making the resident visible from the hallway. The CNA later admitted not providing privacy and dignity, and both the RN supervisor and DON stated that staff are expected to ensure privacy and appropriate coverage during care. Facility admission documents state that residents are to be afforded dignity, respect, and privacy in treatment and care for personal needs.
The facility failed to conduct and document comprehensive investigations into allegations of neglect and abuse. In one case, a cognitively intact resident with cardiac and wound issues had a family member allege neglect after the resident was found with significant leg and foot swelling and was sent to the ED for acute CHF exacerbation; the facility’s investigation did not include interviews with other residents or staff education, despite policy requirements. In another case, a resident with vaginal cancer reported feeling intimidated when a CNA made a threatening remark after an accusation, yet the facility’s investigation did not include abuse-related education or further corrective action, and did not fully consider the CNA’s documented history of prior resident complaints about disrespectful communication, failure to follow resident preferences, and inadequate care setup.
A resident's legal representative, who held POA, requested copies of the resident's medical records but did not receive them due to staff oversight. The request form was completed and signed, but the Medical Records staff, relying on incorrect information, failed to process the request, resulting in the records not being provided as required by facility policy.
A resident with advanced dementia and a chronic facial mass developed a maggot infestation that was not consistently monitored or addressed in the care plan. Staff failed to investigate the cause of the infestation, did not document consistent interventions, and lacked a comprehensive plan to manage the maggots or the resident's refusals of care, resulting in a deficiency in providing care according to professional standards.
A resident with a left facial mass and multiple comorbidities was found with maggots and flies present on the wound, with nursing staff documenting ongoing issues of flies and maggots over several weeks. Despite the facility's pest control policy and regular general pest treatments in common areas, there was no evidence that pest control services were increased or that the resident's room was specifically treated for flies, and staff confirmed that exterminators were not directed to address flies in resident rooms.
Three residents with significant medical needs were transferred to the hospital on multiple occasions without receiving the required transfer and bed hold notices, including information on appeal rights and ombudsman contact details. This lapse occurred after the facility switched to a new EMR system, which did not automatically generate the necessary documentation, and staff did not provide the notices as required.
A resident with a history of dementia and prior ORIF surgery developed a wound that was not promptly or thoroughly assessed by clinical staff. The facility failed to document the wound's type and location, did not consult an orthopedic specialist when hardware was observed protruding, and lacked a care plan for pressure injury prevention prior to the wound's discovery. Physician assessments were incomplete, and oversight of the wound care program was unclear, resulting in delayed and insufficient evaluation and documentation.
Two residents did not receive necessary nutrition services: one experienced significant unaddressed weight loss without timely physician or dietician notification or care plan updates, and another, requiring supervision during meals due to severe cognitive impairment, was repeatedly left unsupervised while eating.
Staff did not follow established recipes when preparing pureed food, instead blending untoasted white bread with liquid cheese powder mix and relying on visual judgment for consistency. The food prepared for residents on pureed diets did not match the regular diet food, and available recipes were not used despite being accessible.
A resident with cognitive and physical impairments did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets, such as built-up utensils, a divided plate, and a nosey cup. Multiple observations showed that the required devices were often missing from the resident's meal trays, despite being documented as necessary and listed on tray tickets. Staff interviews confirmed inconsistencies in the process and a limited supply of certain adaptive items.
A resident with severe cognitive impairment reported being pushed by a CNA. The CNA was suspended and an investigation was conducted, including interviews and a body check that found no injuries. Despite facility policy requiring notification, law enforcement was not contacted regarding the abuse allegation.
The facility failed to provide appropriate pressure ulcer care and accurate documentation for two residents, leading to the deterioration of their wounds. The care plans were not updated, and the physician was not notified of changes in the wounds' presentation.
A resident reported a missing wallet containing money, credit cards, insurance cards, and a driver's license. The Social Worker interviewed the resident's family and staff but did not interview other residents to determine if they had any knowledge of the missing wallet or if they had any personal items missing. The Nursing Home Administrator was informed of the concern, but no further information was provided.
Failure to Provide Privacy and Dignity During Personal Care
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and privacy when a CNA provided personal care to one resident without closing the room door or drawing the privacy curtains. The resident, identified as R3, had been admitted with diagnoses including dementia and age-related osteoporosis, and had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. On 02/19/26 at 5:30 AM, observation from the hallway showed CNA1 at the resident’s bedside performing care while the resident was undressed, with the curtains and door open, making the resident visible from the hallway. During a subsequent interview at 5:37 AM, CNA1 acknowledged that she failed to provide privacy and dignity for the resident by not drawing the curtains and closing the door during care. At 5:40 AM, the nursing supervisor (RN3) stated that her expectation was that CNA1 should have provided privacy and dignity regardless of the time of day. Later, at 6:00 PM, the DON stated it was her expectation that CNA1 should have covered the resident during care. Review of the facility’s undated Admission Agreement showed that the facility committed to ensuring residents’ rights to dignified existence, respect, individuality, consideration, and privacy in treatment and care for personal needs, and to protecting and promoting each resident’s rights.
Failure to Conduct and Document Comprehensive Abuse/Neglect Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough investigation into an allegation of neglect for one resident and to fully evaluate a CNA’s history of concerning interactions with residents during an abuse/neglect investigation. One resident was admitted with diagnoses including myocardial infarction, congestive heart failure, and cellulitis. After a family member reported concern about swelling in the resident’s feet, nursing staff assessed the resident, noted bilateral leg and foot swelling, and recommended emergency room evaluation, after which the resident was admitted to the hospital for acute exacerbation of chronic heart failure. The family member later alleged neglect, and a grievance was filed with the assistance of the social worker. Despite this allegation and the resident’s documented cognitive intactness (BIMS score of 13/15), the facility’s investigation records did not show that other residents were interviewed about neglect concerns or that staff were educated on abuse and neglect policies as part of a comprehensive investigation. The Administrator stated she did not consider it necessary to interview other residents because she viewed the case as unique and without similar concerns among other residents, and she did not consider staff training necessary because she believed there was no actual neglect or abuse in this case. This approach was inconsistent with the facility’s written Abuse, Neglect and Exploitation policy, which requires immediate investigation procedures including identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation. A separate incident involved another resident with vaginal cancer who alleged that a CNA entered her room, came close to her, and stated, “Be sure you know who you accuse,” which the resident reported as intimidating. The facility’s investigation concluded the allegation was unsubstantiated and did not include documentation of abuse-related education or other training for the CNA or staff. Review of the CNA’s personnel file showed multiple prior resident complaints, including telling a resident to be more independent and not ensuring needs were met after providing supplies, using an authoritative tone, yelling at another resident for being wet, making embarrassing comments about incontinence, insisting on clothing choices against resident preference, repeating completed care tasks, and leaving a resident on the toilet long enough to play two games on her phone. Although the CNA had been placed on performance improvement plans for customer service, respectful communication, and resident rights, the Administrator reported she was unaware of all documented concerns and believed she could not use prior personnel records after a change in facility ownership. The facility’s investigation into the later abuse allegation did not reflect a review and integration of this history as part of a comprehensive investigation, contrary to the facility’s policy requiring complete and thorough documentation and focus on determining whether abuse, neglect, or mistreatment occurred.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's legal representative with access to or copies of the resident's medical records upon request. The resident, who had multiple complex diagnoses including fractures, heart disease, dementia, and other chronic conditions, was admitted to the facility and had a power of attorney (POA) designated as his daughter. The facility's policy required that, upon receiving a valid request for medical records, the requesting party should be notified of the cost and records should be made available after payment is received. The policy also specified that records should be gathered and secured once a request is made. Despite these procedures, the resident's daughter/POA submitted a completed and signed request form for the medical records. However, the Medical Records staff member failed to recognize that the form had been filled out and, based on incorrect information from the previous Nursing Home Administrator, believed the form was incomplete. As a result, the request was not processed, and the records were not provided to the resident's representative. This failure was confirmed during the survey when the completed form was found in an envelope, unprocessed, and the staff acknowledged the oversight.
Failure to Develop and Implement Care Plan for Maggot Infestation
Penalty
Summary
A resident with advanced dementia, chronic left facial mass (squamous cell carcinoma), and multiple comorbidities was observed to have a maggot infestation on the facial mass. The resident had a history of refusing treatment for the facial mass, which had been present and growing for at least two years. Despite the presence of a care plan for impaired skin integrity and infection risk, there was no specific care plan or consistent interventions documented for the management of maggots on the resident's facial mass. Nurses' notes and care plans did not consistently address the presence, monitoring, or treatment of maggots, and there was a lack of documentation regarding the number of maggots or the effectiveness of interventions. The facility failed to investigate the cause of the maggot infestation and did not develop or implement a comprehensive plan of care to address the infestation or the resident's refusals of care. Staff interviews revealed inconsistent awareness and documentation of the maggot issue, with some staff reporting direct observation of maggots and others denying any knowledge. The Director of Nursing and RN Supervisor were unable to provide evidence of an investigation into how the infestation occurred or how it was being managed, aside from sporadic notes and a brief incident report that lacked detailed follow-up or staff interviews. Throughout the period of infestation, there was no consistent monitoring or progress notes regarding the presence or removal of maggots, and interventions were sporadic and not clearly documented in the care plan. The lack of a specific maggot care plan, inconsistent monitoring, and absence of a thorough investigation into the infestation represent a failure to provide treatment and care in accordance with professional standards of practice and the resident's needs.
Failure to Address Fly Infestation in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in a resident with a left facial mass being found with maggot-like organisms on the mass. The resident, who had diagnoses including dementia, hypertension, depression, and squamous cell carcinoma of the skin, was observed on multiple occasions to have maggots and flies present on and around the facial wound. Nursing documentation described ongoing issues with maggots and flies, including observations of flies hovering around the resident and worms emerging from the wound. Despite these findings, there was no evidence that pest control services were increased or that the resident's room was specifically treated for flies during the period in question. Review of pest management inspection reports revealed that while general pest control treatments were conducted monthly in common facility areas, there was no documentation of targeted treatment for flies in the affected resident's room. Staff interviews confirmed the presence of flies in the room and indicated that the exterminator was not asked to address flies in resident rooms. The facility's pest control policy required a reporting system for issues arising between scheduled visits and treatment as indicated, but this was not implemented in response to the fly infestation in the resident's room.
Failure to Provide Required Transfer and Bed Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required transfer and bed hold notices to residents and/or their representatives during hospitalizations, as identified for three residents reviewed for hospitalization. Specifically, when residents were transferred to the hospital on multiple occasions, there was no documentation that the residents or their representatives received notices regarding the transfer, the reason for transfer, the location, appeal rights, or contact information for the State Long-Term Care Ombudsman. This deficiency was confirmed through interviews and record reviews, which showed that the facility had not been issuing these notices since switching to a new electronic medical record (EMR) system at the beginning of the year. The affected residents included individuals with significant medical conditions, such as a right leg fracture and chronic kidney disease, who experienced changes in condition necessitating hospitalization. Staff interviews revealed that the previous EMR system automatically generated the required notices, but the new system did not, resulting in a lapse in compliance. Despite some communication with families about bed hold options, there was no evidence that the formal transfer and bed hold notices were provided as required by facility policy and federal regulations.
Failure to Provide Timely and Comprehensive Wound Assessment and Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following the development of a wound. The resident, who had a history of dementia and an ankle fracture treated with open reduction and internal fixation (ORIF), was admitted to the facility and identified as being at risk for pressure ulcers. Despite this risk, there was no care plan in place for pressure injury prevention prior to the discovery of the wound. Upon identification of the wound, the facility did not document a comprehensive assessment to determine the wound type, nor did they specify the wound's location in initial evaluations. The facility's documentation was inconsistent and incomplete regarding the evaluation, assessment, treatment, and outcomes of the resident's wound. The wound was initially documented as an unstageable pressure injury without a clear location, and subsequent records failed to clarify whether the wound was pressure-related or associated with the resident's orthopedic hardware. There was also a lack of timely consultation with an orthopedic specialist when hardware was observed protruding from the resident's skin. Physician assessments did not include comprehensive wound evaluations or documentation of treatment progress, and the wound care plan was not updated until after the wound was discovered. Interviews with facility staff revealed that oversight of the wound care program was unclear, with responsibilities divided between the wound nurse, DON, and a newly hired nurse practitioner. The medical director acknowledged awareness of the hardware protrusion but did not provide documentation of a direct assessment. The wound nurse was unavailable for interview, and the facility was unable to provide evidence of timely or thorough physician evaluation of the wound. Ultimately, a nurse practitioner later determined the wound was related to the internal orthopedic device, not pressure, but this assessment occurred well after the initial deficiency in care and documentation.
Failure to Provide Adequate Nutrition and Supervision During Meals
Penalty
Summary
Two residents did not receive the necessary services to maintain acceptable nutrition and hydration. One resident with multiple diagnoses, including multiple sclerosis, atrial fibrillation, and dementia, experienced a 7.65% weight loss over approximately one month. This significant weight loss was not communicated to the physician or dietician, and there was no evidence of a comprehensive assessment or updated care plan to address the weight loss. The facility's policy required notification of the physician and dietician for significant weight changes, but this was not followed. Additionally, the resident was served food items not appropriate for their prescribed mechanical soft diet, and the correct dessert was not provided as indicated on the meal ticket. The dietary manager reported that weight monitoring was conducted monthly, and significant weight loss would be addressed at the next scheduled meeting. However, there was no documentation that the recent weight loss was addressed promptly or that interventions were implemented based on a comprehensive nutritional assessment. The facility's process for monitoring and responding to weight changes did not ensure timely communication or intervention for the resident's nutritional needs. Another resident with severe cognitive impairment and a care plan requiring supervision or touching assistance with eating was observed on two occasions eating unsupervised in their room. The resident's care plan and facility records indicated the need for supervision during meals, but staff did not provide the required assistance. The resident was left alone with their meal tray, and staff only entered the room briefly to assist with removing lids or to help with toileting, leaving the resident unsupervised for the majority of the meal.
Failure to Follow Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that food prepared for residents on a pureed diet was made according to established recipes designed to conserve nutritive value and flavor. During observation, Cook-C was seen preparing pureed grilled cheese by blending untoasted white bread with liquid cheese powder mix, without following a recipe. When questioned, Cook-C confirmed not using a recipe for pureed foods. The Food Service Manager (FSM)-D also stated that while recipes for pureed foods are available on the computer, they are not used, and the cook relies on visual judgment for consistency. FSM-D further clarified that the pureed food prepared did not match the regular diet food provided to other residents. The facility's policy on pureed food preparation requires that food be prepared to conserve nutritive value, flavor, and appearance, but does not specifically mandate the use of recipes. The recipe provided for pureed grilled cheese called for processing portions of grilled cheese sandwiches from the regular recipe and gradually adding hot milk, but did not specify the number of sandwiches to use. The surveyor found that the method observed did not align with the documented recipe or the food served to residents on a regular diet. No additional information was provided by facility leadership regarding the failure to follow recipes for pureed food.
Failure to Consistently Provide Required Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Parkinson's disease, osteoarthritis, osteoporosis, and unspecified lack of coordination did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets. The resident's care plan and occupational therapy notes indicated the need for built-up silverware, a divided plate, and a small nosey cup to support independent eating and drinking. Despite these documented needs, multiple observations by the surveyor revealed that the resident's meal trays frequently lacked one or more of the required adaptive devices, such as the divided plate and nosey cup, even though these items were listed on the tray tickets. Interviews with facility staff, including dietary aides, certified nursing assistants, and the food service director, confirmed that the process for ensuring adaptive equipment was collaborative, with occupational therapy communicating needs and dietary staff responsible for assembling trays accordingly. However, staff acknowledged inconsistencies in the provision of adaptive equipment, and it was noted that the facility had a limited supply of certain items, such as only one 4-ounce nosey cup, which was not always available for the resident. The surveyor's review of the facility's policy on meal supervision and assistance further highlighted the expectation that trays be checked for correct diet, food consistency, and necessary adaptive devices before serving. Despite this policy, the resident did not consistently receive the adaptive equipment required for independent eating, as evidenced by repeated mismatches between the meal tray tickets and the items actually provided on the trays.
Failure to Notify Law Enforcement of Alleged Abuse
Penalty
Summary
The facility failed to notify law enforcement regarding an allegation of abuse involving a resident with severe cognitive impairment. On 4/20/25, a resident with diagnoses including dementia, chronic kidney disease stage 3, and spinal stenosis reported to an RN Supervisor that a CNA had pushed her. The CNA was immediately suspended pending investigation, and a body check revealed no injuries or discoloration. The facility's investigation included interviews with staff and other residents, and the resident was reinterviewed the following day but did not recall the incident. Despite the facility's policy requiring notification of law enforcement for all alleged violations involving abuse, the investigation documentation did not indicate that law enforcement was notified. The Nursing Home Administrator confirmed to the surveyor that police were not contacted because no injuries were observed on the resident. No further explanation was provided for the failure to report the allegation to law enforcement as required by facility policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice. Specifically, two residents, R43 and R19, were identified as not receiving appropriate pressure ulcer care. R43 was admitted with multiple pressure injuries, including an unstageable pressure injury to the right elbow, which worsened over time. The documentation for R43's wounds was inconsistent and lacked accurate descriptions of staging, measurements, and characteristics. Additionally, the care plan did not adequately address offloading or decreasing pressure on the elbow, leading to further deterioration of the wound. R43 also developed new pressure injuries to the left heel and right Achilles, which were not properly documented or managed according to the facility's policy and procedure for pressure ulcer management. The facility failed to notify the physician of changes in the wound's presentation and did not stage the wound accurately when the base was visible. The care plan was not updated to include recommendations from the wound clinic, and there were inconsistencies in the documentation of the left heel and right Achilles wounds. R43 was eventually transferred to the hospital for cardiac concerns and did not return to the facility during the survey. R19 was admitted with a Stage 3 pressure injury to the right outer ankle, which was not properly managed or documented. The wound did not show significant improvement, and the treatment orders remained unchanged despite the wound's deterioration. The facility failed to notify the physician of changes in the wound's presentation, and the documentation was inconsistent and inaccurate. The hospice RN involved in R19's care did not take measurements of the wound, relying on the facility's documentation, which was found to be inaccurate. The facility's failure to provide appropriate pressure ulcer care and accurate documentation led to the deficiency identified in the survey.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility did not thoroughly investigate an allegation of misappropriation affecting a resident who reported a missing wallet. The wallet contained money, credit cards, insurance cards, and a driver's license. The Social Worker (SW) initiated an investigation by interviewing the resident's family members and staff who worked during the period when the wallet was last seen. However, the SW did not interview any other residents to determine if they had any knowledge of the missing wallet or if they had any personal items missing, which could have broadened the scope of the investigation. The SW acknowledged that they had overheard the resident discussing the missing wallet with other residents, but no further steps were taken to interview those residents. The Nursing Home Administrator (NHA) was informed of the concern that no other residents were interviewed to determine if the incident was isolated or if there was any additional information that could help discover what happened to the wallet. The NHA did not provide any further information at that time.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hales Corners
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clement Manor Health Care Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Greendale Park Nursing And Rehab | 2.5 mi | ★★★★★ | 42 | 0 |
| Maplewood Center | 3 mi | ★★★★★ | 3 | 0 |
| Complete Care At Southpointe | 3.2 mi | ★★★★★ | 19 | 0 |
| Sunrise Health Services | 4 mi | ★★★★★ | 1 | 0 |
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