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Public Record

Complete Care at Nazareth LLC

Nursing HomeStoughton, WICMS 525681
63 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
99

*CMS

Avg. residents per day
61.3

*CMS

Inspection record

On record from CMS

Citations on record
63

*CMS

Inspections on file
10

*CMS

Last inspection
2025-04-02

*CMS

Citations

63 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.

  • 0745Generalpotential for harm

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 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.

  • 0331Generalpotential for harm

    Construct fire resistant interior walls.

  • 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.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0804Generalpotential for harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0812Generalpotential for harm

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

  • 0232Generalpotential for harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0686Generalpotential for harm

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

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0761Generalpotential for harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  • 0521Generalpotential for harm

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

  • 0006Generalpotential for harm

    Conduct risk assessment and an All-Hazards approach.

  • 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.

  • 0689Seriousimmediate jeopardy

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0804Generalpotential for harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0554Generalpotential for harm

    Allow residents to self-administer drugs if determined clinically appropriate.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0013Generalpotential for harm

    Develop Emergency Preparedness policies and procedures.

  • 0132Generalpotential for harm

    Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

  • 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.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 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.

  • 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.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0521Generalpotential for harm

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

  • 0531Generalpotential for harm

    Have elevators that firefighters can control in the event of a fire.

  • 0911Generalpotential for harm

    Meet requirements for the installation and maintenance of electrical systems.

  • 0912Generalpotential for harm

    Have power receptacles that are properly grounded.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0686Seriousimmediate jeopardy

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

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0812Generalpotential for harm

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

  • 0697Seriousactual harm

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0689Seriousactual harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 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.

  • 0351Generalpotential for harm

    Install an approved automatic sprinkler system.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0914Generalpotential for harm

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

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0291Generalpotential for harm

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

  • 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.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

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 Nazareth LLC?
Complete Care at Nazareth LLC is a Medicare- and Medicaid-certified nursing home in Stoughton, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525681.
What is the CMS rating for Complete Care at Nazareth LLC?
Complete Care at Nazareth 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 Nazareth LLC have?
Complete Care at Nazareth LLC is certified for 99 beds. It serves an average of 61.3 residents per day.
How many citations does Complete Care at Nazareth LLC have?
Complete Care at Nazareth LLC has 63 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Complete Care at Nazareth LLC last inspected?
Complete Care at Nazareth LLC was last inspected on April 2, 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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