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Public Record

Complete Care at Jefferson Meadows LLC

Nursing HomeBaraboo, WICMS 525317
46 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
102

*CMS

Avg. residents per day
50.2

*CMS

Inspection record

On record from CMS

Citations on record
46

*CMS

Inspections on file
6

*CMS

Last inspection
2025-05-13

*CMS

Citations

46 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.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0849Generalpotential for harm

    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.

  • 0880Generalno actual harm

    Provide and implement an infection prevention and control program.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0740Generalpotential for harm

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0281Generalpotential for harm

    Install proper backup exit lighting.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0754Generalpotential for harm

    Provide properly sized and located linen or trash receptacles.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0679Generalpotential for harm

    Provide activities to meet all resident's needs.

  • 0692Seriousactual harm

    Provide enough food/fluids to maintain a resident's health.

  • 0693Generalpotential for harm

    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.

  • 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.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0700Seriousimmediate jeopardy

    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.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0911Generalpotential for harm

    Meet requirements for the installation and maintenance of electrical systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0688Generalpotential for harm

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0604Generalpotential for harm

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  • 0686Seriousimmediate jeopardy

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 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.

  • 0223Generalpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0583Generalpotential for harm

    Keep residents' personal and medical records private and confidential.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Complete Care at Jefferson Meadows LLC?
Complete Care at Jefferson Meadows LLC is a Medicare- and Medicaid-certified nursing home in Baraboo, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525317.
What is the CMS rating for Complete Care at Jefferson Meadows LLC?
Complete Care at Jefferson Meadows LLC has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Complete Care at Jefferson Meadows LLC have?
Complete Care at Jefferson Meadows LLC is certified for 102 beds. It serves an average of 50.2 residents per day.
How many citations does Complete Care at Jefferson Meadows LLC have?
Complete Care at Jefferson Meadows LLC has 46 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Complete Care at Jefferson Meadows LLC last inspected?
Complete Care at Jefferson Meadows LLC was last inspected on May 13, 2025. 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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