SNF
Complete Care at Germantown
CCN: 525653 · Germantown, WI 53022 · Washington County
Overview
- Address
- W173 N10915 Bernies Way, Germantown, WI 53022
- Phone
- 2625093300
- Certified beds
- 121
- Avg daily residents
- 52 (43% of beds filled)
- Ownership
- For-profit LLC
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1999-10-14
- Setting
- Urban
4 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.60 | 4.65 | 2.99 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.91 | 0.81 | 0.76 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.58 | 1.03 | 0.48 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.10 | 2.80 | 1.75 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.49 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.04 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.16
hrs / resident / day
RN (weekend)
0.70
hrs / resident / day
Total nurse (adjusted, weekend)
2.63
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
59.1%
annual
RN turnover
40.0%
annual
Administrators departed
1
last 12 months
Resident acuity
Nursing Case-Mix Index
1.65
higher acuity than avg
Case-Mix Index Ratio
1.20
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-03-05 | 4 | 4 | 0 | 20 | 1 | 20 |
| Cycle 2/3 (prior) | 2024-01-24 | 14 | 3 | 12 | 64 | 1 | 64 |
Total weighted health score
31.0
lower is better
Deficiencies (29)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
29 D/E/F Actual harm — potential for minor
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0551 | Give the resident's representative the ability to exercise the resident's rights. | D | 2025-03-05 | 2025-03-21 |
| 0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | 2025-03-05 | 2025-03-24 |
| 0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | 2025-03-05 | 2025-03-25 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2025-03-05 | 2025-03-25 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | 2025-01-30 | 2025-03-01 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2024-07-17 | 2024-08-16 |
| 0610 | Respond appropriately to all alleged violations. | D | 2024-07-17 | 2024-08-16 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2024-05-08 | 2024-06-08 |
| 0610 | Respond appropriately to all alleged violations. | D | 2024-05-08 | 2024-06-08 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | 2024-01-24 | 2024-02-23 |
| 0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | D | 2024-01-24 | 2024-02-23 |
| 0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | 2024-01-24 | 2024-02-23 |
| 0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | 2023-11-07 | 2023-11-23 |
| 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | 2023-11-07 | 2023-12-01 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2023-10-25 | 2023-11-23 |
| 0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | 2023-10-25 | 2023-11-23 |
| 0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | 2023-10-25 | 2023-11-23 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2023-10-25 | 2023-11-23 |
| 0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D | 2022-11-10 | 2022-12-08 |
| 0660 | Plan the resident's discharge to meet the resident's goals and needs. | D | 2022-11-10 | 2022-12-08 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2022-11-10 | 2022-12-08 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2022-11-10 | 2022-12-08 |
| 0692 | Provide enough food/fluids to maintain a resident's health. | D | 2022-11-10 | 2022-12-08 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2022-11-10 | 2022-12-08 |
| 0759 | Ensure medication error rates are not 5 percent or greater. | E | 2022-11-10 | 2022-12-08 |
| 0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | 2022-11-10 | 2022-12-08 |
| 0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | D | 2022-11-10 | 2022-12-08 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2022-11-10 | 2022-12-08 |
| 0908 | Keep all essential equipment working safely. | F | 2022-11-10 | 2022-12-08 |
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 7.3% Medicaid 73.9% Other 18.8%
Operating performance
Operating Margin
9.8%
Total Margin
10.0%
Occupancy Rate
52.3%
Cost per Resident Day
$26
Revenue & costs
Net Patient Revenue
$8.2M
Total Costs
$603K
Net Income
$822K
Balance sheet
Total Assets
$1.8M
Total Liabilities
$1.2M
Fund Balance
$617K
Current Ratio
1.47
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: COMPLETE CARE
- Chain ID
157- Facilities in chain
- 85
- Legal business name
- VIRGINIA HIGHLANDS CARE AND REHAB CENTER LLC
Chain-average star ratings (for peer context)
Overall
3.2
Health
2.7
Staffing
2.5
QM
4.4
Owner / manager organizations (4)
| Organization | Role | Association |
|---|---|---|
| PC SWI HOLDCO LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 06/01/2022 |
| PC SWI TOPCO LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/01/2022 |
| PEACE CAPITAL HOLDINGS LLC (DE) | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/01/2022 |
| SMS 2021 TRUST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/01/2022 |
Owner / manager individuals (6)
| Name | Role | Association |
|---|---|---|
| BIELINSKI, RENEE | OPERATIONAL/MANAGERIAL CONTROL | since 07/11/2022 |
| HALE, CASSANDRA | OPERATIONAL/MANAGERIAL CONTROL | since 01/22/2024 |
| HELMAN, YOSEF | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2022 |
| SIDHU, SARFRAZ | OPERATIONAL/MANAGERIAL CONTROL | since 05/15/2023 |
| SPITZER, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | since 03/26/2025 |
| STEIN, SHALOM | CORPORATE OFFICER | since 06/01/2022 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $26 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 1.47 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 73.9% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 7.3% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $822,084 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $8,242,449 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 52.3% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | 9.8% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $1,800,168 | metrics.total_assets |
| Cost Report | Total Costs ($) | $603,454 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $617,148 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $1,183,020 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | 10.0% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.48339 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 1.74596 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.75771 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 2.98706 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 2.62809 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 52.0 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 1.03164 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.80378 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.81316 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 4.64859 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 4.09724 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.7 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 3.2 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.4 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 2.5 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 157 | Chain ID |
| Provider Information | Chain Name | COMPLETE CARE | Chain Name |
| Provider Information | City/Town | Germantown | City/Town |
| Provider Information | CMS Certification Number (CCN) | 525653 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Washington | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1999-10-14 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | 22 | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 4 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 43.2244 | Latitude |
| Provider Information | Legal Business Name | VIRGINIA HIGHLANDS CARE AND REHAB CENTER LLC | Legal Business Name |
| Provider Information | Location | W173 N10915 Bernies Way,Germantown,WI,53022 | Location |
| Provider Information | Long-Stay QM Rating | 4 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -88.145 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 1 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 121 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 85 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.64679 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 1.19536 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 4 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Limited Liability company | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | W173 N10915 Bernies Way | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Complete Care at Germantown | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 650 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 4 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 20 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 0 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 4 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-03-05 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 20 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 4 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 3 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-01-24 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 64 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 12 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 64 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 14 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.69581 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 40.0 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.49430 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.58201 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.10214 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.03762 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.91229 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.59644 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 4 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 2 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | WI | State |
| Provider Information | Telephone Number | 2625093300 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.16424 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 59.1 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 31.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 53022 | ZIP Code |