Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Germantown during CMS and state inspections, most recent first.
Surveyors found that staff did not follow approved food cooling methods or document the cooling process for pre-cooked foods, resulting in multiple items being stored in the cooler for several days and pre-cooked spaghetti being served to residents without proper documentation of safe cooling procedures.
A resident with a court-appointed guardian and multiple complex medical conditions remained in the facility beyond 60 days without the required protective placement order. Staff interviews and record review showed that neither the Social Services Designee nor the DON initiated the necessary legal process, resulting in noncompliance with state statute.
A resident with multiple mental health diagnoses was not properly screened through the PASRR Level II process. Despite repeated attempts by a QMHP to obtain necessary information from the facility, no response was provided, leading to the cancellation of the PASRR Level II Screen. The required re-submission was not completed due to the absence of the Social Services Designee and lack of coverage.
The facility failed to ensure accurate medication administration for five residents, as medications were found at their bedsides without proper assessments or physician orders for self-administration. Residents were observed with medications, and none had the necessary assessments, physician orders, or care plans indicating they could safely self-administer medications. Staff were unaware of the residents' ability to self-administer medications, and the Nursing Home Administrator confirmed the oversight.
A facility failed to report allegations of abuse and misappropriation involving three residents. An altercation between two residents resulted in one sustaining injuries, but the incident was not reported to authorities as required. Additionally, a resident's missing wallet was not investigated or reported. The facility did not adhere to its policies for reporting suspected abuse and misappropriation.
The facility failed to investigate allegations of abuse and misappropriation involving three residents. In one case, a resident sustained injuries during an altercation with another resident, but the incident report lacked thorough investigation. In another case, a resident's wallet went missing, but no investigation or documentation was conducted. The facility's policy requires immediate investigation, which was not followed.
The facility failed to ensure timely reporting of an injury of unknown origin and an allegation of sexual abuse to the NHA, SA, and local law enforcement. In one case, a resident's fracture was not immediately reported, and in another, an allegation of rape was delayed in being reported. Both incidents highlight a failure in adhering to the facility's reporting procedures.
A resident with severe cognitive impairment accused an LPN of sexual abuse, but the facility did not remove the LPN from resident care during the investigation. Despite the facility's policy to protect residents by making staffing changes, the LPN continued to work with residents. The allegation was not substantiated, but the facility failed to follow its own policy.
Failure to Properly Cool and Document Food Storage
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, specifically by not following approved food cooling methods. During a kitchen tour, surveyors observed multiple cooked food items in the cooler, including ground beef, turkey, spaghetti sauce with noodles and ground beef, ground sausage, beef casserole, and shredded pork, some of which had been stored for several days. The Dietary Manager (DM) indicated that leftovers should not be saved for future meals and are typically discarded every Monday, but several items were found in the cooler with dates indicating they had been kept beyond a single meal period. Further observation revealed that pre-cooked spaghetti was reheated and served to residents for lunch, but there was no documentation of the cooling process for this food. The DM was unable to provide a cooling log for the spaghetti and confirmed that, although the spaghetti was believed to have been properly cooled, the process was not documented as required by facility policy. The lack of documentation and adherence to proper cooling procedures for pre-cooked foods constituted a failure to comply with professional food safety standards.
Failure to Obtain Protective Placement for Resident with Guardian
Penalty
Summary
The facility failed to ensure that protective placement was obtained for a resident with a court-appointed guardian whose stay exceeded 60 days. The resident, who had diagnoses including dementia without behavioral disturbance, stage 4 pressure injury, adult failure to thrive, dysphagia, and osteomyelitis of the vertebra, was admitted with a guardian in place. According to Wisconsin State Statute 55.055(1)(b), a guardian may consent to admission for up to 60 days, after which a petition for protective placement must be initiated if the stay is to continue. Record review and staff interviews revealed that the facility did not initiate or obtain the required protective placement paperwork for the resident after the initial 60-day period. The Social Services Designee was unaware of the need for further action beyond the guardian's consent, and the Director of Nursing confirmed that no protective placement order was present in the resident's record. The lack of protective placement was only identified after the surveyor's inquiry, indicating that the statutory requirements for continued admission were not met.
Failure to Complete PASRR Level II Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with multiple mental health diagnoses, including schizophrenia, bipolar disorder, sleep terrors, panic disorder, post-traumatic stress disorder, and adjustment disorder with anxiety, was properly screened through the Pre-Admission Screen and Resident Review (PASRR) Level II process. The resident's medical record showed a Brief Interview for Mental Status (BIMS) score indicating intact cognition. A Qualified Mental Health Professional (QMHP) attempted to obtain additional information from the facility on three separate occasions to complete the PASRR Level II determination but received no response. As a result, the QMHP canceled the PASRR Level II Screen due to insufficient information and instructed that a new PASRR Level II should be submitted if the resident remained in the facility. The Social Services Designee confirmed that the PASRR was not re-submitted because they were out of the office and there was no coverage during their absence.
Failure to Ensure Accurate Medication Administration
Penalty
Summary
The facility failed to ensure the accurate administration of drugs and biologicals for five residents, as medications were found at their bedsides without proper assessments or physician orders for self-administration. The facility's policy requires that each resident be assessed for the ability to self-administer medications, and that care plans reflect this capability along with storage arrangements. However, residents R5, R20, R4, R7, and R9 were observed with medications at their bedsides, and none had the necessary assessments, physician orders, or care plans indicating they could safely self-administer medications. During the survey, it was noted that R5 self-administered eye drops without proper authorization, and R9 had a blue pill on a paper towel, unsure of its identity, which was later taken without confirmation of its purpose. LPN-C, a staff member, was unaware of the residents' ability to self-administer medications and could not identify the pill found in R9's room. The Nursing Home Administrator confirmed the lack of assessments and care plans for these residents, acknowledging the oversight in following the facility's policy for self-administration of medications.
Failure to Report Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property to the State Agency (SA) or local law enforcement for three residents. Specifically, a resident-to-resident altercation occurred between two residents, resulting in one resident sustaining a physical injury. The Director of Nursing was informed of the incident, but the facility did not report the allegation of abuse as required by their policy. The policy mandates reporting alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. In the incident involving the two residents, a Certified Nursing Assistant (CNA) witnessed one resident swinging a call light in another resident's room, leading to a struggle and resulting in the injured resident sustaining lacerations on the face. The CNA was the only eyewitness, and no additional staff statements were obtained. The injured resident had severely impaired cognition, while the other resident had moderately impaired cognition. Despite the altercation and injury, the facility did not report the incident to the appropriate authorities. Additionally, the facility failed to report a suspected misappropriation of property involving another resident. This resident reported a missing wallet containing a debit card and cash several months prior, but no grievance or investigation was documented. The Regional Director recalled the incident and was informed that an investigation and report would be conducted, but no reports were made to the SA or local law enforcement. The facility's inaction in both cases demonstrates a failure to adhere to their policies and procedures for reporting suspected abuse and misappropriation.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving three residents. In the first incident, a resident-to-resident altercation occurred between two residents, resulting in one resident sustaining lacerations on the forehead and eyebrow. The incident report, completed by the Director of Nursing, did not include additional interviews with residents or staff, nor did it determine if abuse occurred. A Certified Nursing Assistant (CNA) provided a statement that contradicted the incident report, indicating a lack of thorough investigation. In the second incident, a resident reported their wallet, debit card, and cash missing. Despite the resident's report and a search conducted by four staff members, the facility did not document a grievance or conduct an investigation into the alleged misappropriation. Interviews with the Nursing Home Administrator, a CNA, and a Social Services Assistant revealed a lack of awareness and documentation regarding the missing wallet. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and thorough documentation, which was not adhered to in these cases. The Nursing Home Administrator confirmed the findings and acknowledged the lack of a thorough investigation for both incidents. The Regional Director also verified that an investigation into the suspected misappropriation was not completed.
Failure to Timely Report Abuse and Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin and an allegation of sexual abuse to the Nursing Home Administrator (NHA), the State Agency (SA), and local law enforcement. For one resident, a fracture of unknown origin was discovered, but staff did not immediately report the injury to the NHA, delaying the facility's report to the SA. The resident, who had moderately impaired cognition and required assistance for transfers, was improperly transferred by a Certified Nursing Assistant (CNA), leading to the injury. The CNA was later suspended and terminated for not following the resident's care plan and being untruthful about the incident. In another case, a resident with severely impaired cognition alleged that a male nurse attempted to rape them. The allegation was reported by the resident's daughter to the facility, but staff did not immediately inform the administration, delaying the report to the SA and local law enforcement. The Director of Nursing (DON) was only made aware of the allegation the following morning, indicating a failure in the timely reporting process. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of such incidents to the appropriate authorities. However, in both cases, the staff failed to adhere to these procedures, resulting in delays in reporting and investigation. The facility had previously provided staff education on when to call the NHA/DON, but this education was not effectively implemented in these instances.
Failure to Remove LPN During Sexual Abuse Investigation
Penalty
Summary
The facility did not prevent further potential abuse during an investigation of sexual assault for one resident (R2). R2 accused an LPN of sexual abuse, but the facility did not remove the LPN from resident care pending the results of the investigation. The facility's policy indicates that staff should respond immediately to protect residents, including making staffing changes and increasing supervision. However, the LPN continued to work on multiple dates following the allegation. R2, who had severe cognitive impairment and an activated Power of Attorney for Healthcare, alleged that a male nurse tried to touch their private parts. Despite this, the Director of Nursing (DON) did not remove the LPN from resident care, citing that the LPN did not match the description of the alleged perpetrator. The investigation included interviews with staff and a review of nursing schedules, which confirmed that the LPN continued to work with residents during the investigation period. The allegation of abuse was ultimately not substantiated, but the facility failed to follow its own policy to protect residents during the investigation.
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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 Germantown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Menomonee Falls Health Services | 5.6 mi | — | 1 | 0 |
| Lindengrove Menomonee Falls | 5.6 mi | — | 15 | 1 |
| Avina Of Milwaukee | 7.6 mi | — | 49 | 0 |
| Lasata Care Center | 8 mi | — | 8 | 0 |
| Cedarburg Health Services | 8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.