Complete Care at Jefferson Meadows LLC
1414 Jefferson St., Baraboo, WI 53913
Complete Care at Jefferson Meadows LLC is a nursing home in Baraboo, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (608) 356-4838
- Last standard health inspection
- July 21, 2026 (3 months ago)
- Certified beds
- 102
- Residents per day, on average
- 47.4
- Ownership type
- For profit - Limited Liability company
- Legal business name
- St Clare Care and Rehab Center LLC
- Chain
- Complete Care
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (24 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
8 citations
Health inspection on July 21, 2026
CMS lists this as a standard inspection.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on August 13, 2026.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on August 13, 2026.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on August 13, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on August 13, 2026.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on August 13, 2026.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on August 13, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on August 13, 2026.
CMS has cited this home for F0760 2 times since 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on August 13, 2026.
11 citations
Fire safety inspection on July 21, 2026
CMS lists this as a standard inspection.
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on August 13, 2026.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on December 31, 2026.
CMS has cited this home for K0521 2 times since 2024.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on August 13, 2026.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 13, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 13, 2026.
Citation K0927. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on August 13, 2026.
Citation K0132. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
CMS lists it as corrected on August 13, 2026.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 13, 2026.
CMS has cited this home for K0321 2 times since 2025.
Citation K0347. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on August 19, 2026.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on August 13, 2026.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on August 13, 2026.
CMS has cited this home for K0911 2 times since 2024.
1 citation
Health inspection on July 2, 2026
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 15, 2026.
CMS update of May 27, 2026
Fine
CMS changed the fine from January 31, 2025 from $54,140 to $35,191.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of March 25, 2026
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Name
CMS lists a new name for this home. It was ST CLARE CARE AND REHAB CENTER.
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.0 to 2.3 hours per resident per day.
CMS update of June 25, 2025
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
CMS update of May 28, 2025
Name
CMS lists a new legal business name for this home.
14 citations
Health inspection on May 13, 2025
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 10, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 10, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 10, 2025.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on June 10, 2025.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on June 10, 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 10, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 10, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on June 10, 2025.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on June 10, 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on June 10, 2025.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on June 10, 2025.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 10, 2025.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 10, 2025.
Citation F0880. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 10, 2025.
11 citations
Fire safety inspection on May 13, 2025
CMS lists this as a standard inspection.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on June 10, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 10, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 10, 2025.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 10, 2025.
CMS has cited this home for K0363 2 times since 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 10, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 10, 2025.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on June 10, 2025.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 10, 2025.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on June 10, 2025.
Citation K0754. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly sized and located linen or trash receptacles.
CMS lists it as corrected on June 10, 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 10, 2025.
Fine
May 13, 2025 (1 year ago)
CMS fine of $19,135 on May 13, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Name
CMS lists a new name for this home. It was SSM HEALTH ST CLARE MEADOWS CARE CTR.
1 citation
Health inspection on January 31, 2025
CMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0700. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 21, 2025.
Fine
January 31, 2025 (1 year ago)
CMS fine of $35,191 on January 31, 2025.
CMS update of December 20, 2024
Ownership
CMS ownership records list new owners for this home.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of August 29, 2024
Ownership
CMS ownership records list new owners for this home.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
6 citations
Fire safety inspection on May 14, 2024
CMS lists this as a standard inspection.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on May 24, 2024.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on May 24, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 24, 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 7, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 24, 2024.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on May 24, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.5 to 3.6 hours per resident per day.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- PC WCM OPCO HOLDCO LLC5% or greater direct ownership interest · 100% · since 02/28/2025
- PC WCM TOPCO LLC5% or greater indirect ownership interest · no percentage provided · since 02/28/2025
- PEACE CAPITAL HOLDINGS II LLC5% or greater indirect ownership interest · no percentage provided · since 02/28/2025
- SMS 2021 TRUST5% or greater indirect ownership interest · no percentage provided · since 02/28/2025
- KLUGMAN, JACOBIndirect ownership interest · not applicable · since 02/28/2025
- STEIN, SHALOMIndirect ownership interest · not applicable · since 02/28/2025
- FLYGT, THOMASOperational/managerial control · not applicable · since 02/28/2025
- GREENWOOD, EMILYOperational/managerial control · not applicable · since 02/28/2025
- HELLMAN, YOSEFOperational/managerial control · not applicable · since 02/28/2025
- PENDLETON, JULIEOperational/managerial control · not applicable · since 02/28/2025
- STERNBUCH, DANIELOperational/managerial control · not applicable · since 02/28/2025
Questions
When was Complete Care at Jefferson Meadows LLC last inspected?
CMS lists July 21, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Complete Care at Jefferson Meadows LLC have?
CMS lists 24 health citations since January 31, 2025. CMS also calls these deficiencies.
Has Complete Care at Jefferson Meadows LLC been fined?
CMS lists 2 fines in the past three years, $54,326 in total.
What is the CMS star rating of Complete Care at Jefferson Meadows LLC?
Its CMS overall star rating is 2 of 5.
Is Complete Care at Jefferson Meadows LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.