Public Record
Complete Care at Southpointe
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 174
- Avg. residents per day
- 99.1
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 61
- Inspections on file
- 7
- Last inspection
- 2026-03-12
*CMS
*CMS
*CMS
Citations
61 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0908Generalpotential for harm
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0341Generalpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0041Generalpotential for harm
Implement emergency and standby power systems.
- 0031Generalpotential for harm
Provide emergency officials' contact information.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0623Generalno actual harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0686Seriousimmediate jeopardy
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Seriousactual harm
Provide enough food/fluids to maintain a resident's health.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0361Generalpotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0541Generalpotential for harm
Install properly constructed and protected linen or trash chutes.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0758Generalpotential for harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0761Generalpotential for harm
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.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0886Generalno actual harm
Perform COVID19 testing on residents and staff.
- 0943Generalpotential for harm
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0678Seriousimmediate jeopardy
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0580Seriousactual harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0222Generalpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0700Generalpotential for harm
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.
FAQ
Questions and answers
- What is Complete Care at Southpointe?
- Complete Care at Southpointe is a Medicare- and Medicaid-certified nursing home in Greenfield, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525604.
- What is the CMS rating for Complete Care at Southpointe?
- Complete Care at Southpointe has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Complete Care at Southpointe have?
- Complete Care at Southpointe is certified for 174 beds. It serves an average of 99.1 residents per day.
- How many citations does Complete Care at Southpointe have?
- Complete Care at Southpointe has 61 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Complete Care at Southpointe last inspected?
- Complete Care at Southpointe was last inspected on March 12, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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