Complete Care at Nazareth LLC
814 Jackson St., Stoughton, WI 53589
Complete Care at Nazareth LLC is a nursing home in Stoughton, 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
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (608) 873-6448
- Last standard health inspection
- April 2, 2026 (7 months ago)
- Certified beds
- 99
- Residents per day, on average
- 63.8
- Ownership type
- For profit - Corporation
- Legal business name
- Complete Care at Nazareth LLC
- Chain
- Complete Care
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (27 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.
3 citations
Health inspection on June 10, 2026
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
Citation F0689. Severity J: immediate jeopardy, 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 May 13, 2026.
CMS has cited this home for F0689 5 times since 2023.
Citation F0658. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on July 6, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
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 July 6, 2026.
Fine
June 10, 2026 (5 months ago)
CMS fine of $26,310 on June 10, 2026.
9 citations
Health inspection on April 2, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0809. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
CMS lists it as corrected on April 27, 2026.
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 April 27, 2026.
CMS has cited this home for F0812 3 times since 2023.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on April 27, 2026.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0880 3 times since 2023.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on April 27, 2026.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on April 27, 2026.
CMS has cited this home for F0804 3 times since 2023.
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 April 27, 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 April 27, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
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 April 27, 2026.
10 citations
Fire safety inspection on April 2, 2026
CMS lists this as a standard inspection.
Citation E0029. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop a communication plan.
CMS lists it as corrected on April 27, 2026.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on April 27, 2026.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 27, 2026.
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 April 27, 2026.
CMS has cited this home for K0353 3 times since 2023.
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 April 27, 2026.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 27, 2026.
CMS has cited this home for K0222 3 times since 2023.
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 April 27, 2026.
CMS has cited this home for K0223 2 times since 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 27, 2026.
CMS has cited this home for K0363 3 times since 2023.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on April 27, 2026.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
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 April 27, 2026.
CMS has cited this home for K0521 3 times since 2023.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Name
CMS lists a new name for this home. It was NAZARETH HEALTH AND REHAB CENTER.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of May 28, 2025
Fine
CMS changed the fine from September 30, 2024 from $24,065 to $15,642.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
1 citation
Health inspection on April 2, 2025
CMS lists this as a complaint inspection.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on April 21, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
6 citations
Health inspection on January 9, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on February 3, 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 February 3, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on February 3, 2025.
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 February 3, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 3, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 3, 2025.
13 citations
Fire safety inspection on January 9, 2025
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on February 3, 2025.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on February 3, 2025.
CMS has cited this home for K0311 2 times since 2023.
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 February 3, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on February 3, 2025.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 3, 2025.
Citation K0232. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on February 3, 2025.
Citation K0331. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Construct fire resistant interior walls.
CMS lists it as corrected on February 3, 2025.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 3, 2025.
CMS has cited this home for K0345 2 times since 2023.
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 February 3, 2025.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 3, 2025.
CMS has cited this home for K0374 2 times since 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 3, 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 February 3, 2025.
CMS has cited this home for K0321 2 times since 2023.
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 February 3, 2025.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Payment stopped
October 22, 2024 (2 years ago)
CMS stopped payment for new admissions from October 22, 2024, for 20 days.
1 citation
Health inspection on September 30, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
Citation F0689. Severity J: immediate jeopardy, 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 November 11, 2024.
Fine
September 30, 2024 (2 years ago)
CMS fine of $15,642 on September 30, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from July 20, 2023 from $25,847 to $16,801.
CMS update of May 29, 2024
Fine
CMS changed the fine from July 20, 2023 from $123,275 to $25,847.
CMS update of April 25, 2024
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.
7 citations
Health inspection on November 30, 2023
CMS lists this as a standard inspection.
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 December 27, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 27, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on December 27, 2023.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on December 27, 2023.
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 December 27, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 27, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on December 27, 2023.
14 citations
Fire safety inspection on November 30, 2023
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 January 25, 2024.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
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 January 25, 2024.
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 January 25, 2024.
Citation K0911. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on January 12, 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 December 27, 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on December 27, 2023.
Citation K0531. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have elevators that firefighters can control in the event of a fire.
CMS lists it as corrected on January 12, 2024.
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 December 27, 2023.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
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 December 27, 2023.
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 December 27, 2023.
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 December 27, 2023.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on December 27, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- EEF CAPITAL LLC5% or greater direct ownership interest · 40% · since 06/01/2018
- SNJ WISCONSIN LLC5% or greater direct ownership interest · 60% · since 06/01/2018
- SCHLAFF, BENNY5% or greater indirect ownership interest · 20% · since 06/01/2018
- SCHLAFF, NACHUM5% or greater indirect ownership interest · 20% · since 06/01/2018
- SILVERBERG, NISANEL5% or greater indirect ownership interest · 11% · since 06/01/2018
- CULP, KARENOperational/managerial control · not applicable · since 02/03/2020
- HELLMAN, YOSEFOperational/managerial control · not applicable · since 06/01/2018
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 07/01/2024
- WILLIAMS, JASONOperational/managerial control · not applicable · since 08/21/2023
Questions
When was Complete Care at Nazareth LLC last inspected?
CMS lists April 2, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Complete Care at Nazareth LLC have?
CMS lists 27 health citations since November 30, 2023. CMS also calls these deficiencies.
Has Complete Care at Nazareth LLC been fined?
CMS lists 2 fines in the past three years, $41,952 in total.
What is the CMS star rating of Complete Care at Nazareth LLC?
Its CMS overall star rating is 2 of 5.
Is Complete Care at Nazareth LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.