Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Complete Care at Southpointe

Greenfield, WI · 174 certified beds · Last Life Safety survey March 12, 2026

CMS Certification Number 525604 · first certified September 1996

Ownership

Operated by COMPLETE CARE · For profit - Limited Liability company

Ownership changed June 1, 2022 (change of ownership)from SSC GREENFIELD OPERATING COMPANY LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WI

28 citations — more than 80% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 12 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens April 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 28 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	28
Median facility in WI	17
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 17, 2023	6
October 17, 2024	10
March 12, 2026	12

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0923	Have proper medical gas storage and administration areas.	3	2026-03-12
K-0341	Install a fire alarm system that can be heard throughout the facility.	2	2026-03-12
K-0293	Have properly located and lighted "Exit" signs.	2	2026-03-12
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2026-03-12
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2026-03-12
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	1	2024-10-17
E-0031	Provide emergency officials' contact information.	1	2024-10-17
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	1	2026-03-12

What the citations cover

Citations by CMS category

Gas, Vacuum, and Electrical Systems Deficiencies 8
Smoke Deficiencies 8
Miscellaneous Deficiencies 5
Egress Deficiencies 3
Other 4

Citations by CMS category
Category	Citations
Gas, Vacuum, and Electrical Systems Deficiencies	8
Smoke Deficiencies	8
Miscellaneous Deficiencies	5
Egress Deficiencies	3
Emergency Preparedness Deficiencies	2
Services Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 12, 2026 — 12 citations

Citations issued on March 12, 2026
Tag	What the surveyor checks	Status
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has plan of correction
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (April 5, 2026)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (April 5, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (April 5, 2026)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has plan of correction
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has plan of correction
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (April 5, 2026)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 5, 2026)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (April 5, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (April 5, 2026)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (April 5, 2026)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (April 5, 2026)

October 17, 2024 — 10 citations

Citations issued on October 17, 2024
Tag	What the surveyor checks	Status
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (October 17, 2024)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (November 13, 2024)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Waiver has been granted (January 31, 2025)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Waiver has been granted (January 31, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 12, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (October 17, 2024)
K-0908	Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.	Deficient, Provider has date of correction (November 11, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (October 17, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 12, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (October 17, 2024)

August 17, 2023 — 6 citations

Citations issued on August 17, 2023
Tag	What the surveyor checks	Status
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (September 11, 2023)
K-0361	Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.	Waiver has been granted (February 13, 2024)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (September 11, 2023)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (September 11, 2023)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (September 11, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (September 11, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.