Federal inspection record · CMS data as of October 1, 2026
Complete Care at Jefferson Meadows LLC
1414 Jefferson St., Baraboo, WI · (608) 356-4838
- Certified beds
- 102
- Residents per day
- 47
- Ownership
- For-Profit
- Chain
- Complete Care
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 1, 1982
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Complete Care at Jefferson Meadows LLC carries 90.25 inspection points. That is fewer than 35% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
24 health citations on record since 2025. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
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G
Provide enough food/fluids to maintain a resident's health.
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K
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.
Everything else, by area of care
Quality of Life and Care7D
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide activities to meet all resident's needs.
- D
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.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Resident Assessment and Care Planning3E
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Pharmacy Service3E
- D
Ensure that residents are free from significant medication errors.
- E
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.
- D
Ensure that residents are free from significant medication errors.
Administration2F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- D
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.
Infection Control2E
- E
Implement a program that monitors antibiotic use.
- C
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Respond appropriately to all alleged violations.
Resident Rights1D
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspection history
2026-07-21
9 health deficiencies · 11 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2025-05-13
15 health deficiencies · 11 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2024-05-14
0 health deficiencies · 6 fire-safety deficiencies
No concentrated health issue counts in this cycle.
4
Nursing time per resident, per day
Each resident here gets about 4 h 4 min of nursing staff time a day, 1 h 9 min of it from a registered nurse.
This home
4 h 4 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 60% of nursing staff and 50% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$54,326 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-05-13 | Fine | $19,135 |
| 2025-01-31 | Fine | $35,191 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts better | 1.4 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.3 pts better | 1.9 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine14.1 pts worse | 81.9% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.4 pts better | 100.0% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury3.3 pts better | 0.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms46.7 pts worse | 52.7% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.6 pts worse | 5.5% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.6 pts better | 11.2% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication9.8 pts better | 6.1% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened12.2 pts worse | 29.2% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased1.2 pts better | 14.6% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.8 pts worse | 2.7% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.5 pts better | 1.2% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence8.1 pts worse | 31.7% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.9 pts better | 1.0% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine53.2 pts worse | 33.7% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2 pts worse | 17.6% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine5.7 pts worse | 76.5% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.5 pts worse | 24.0% | 22.5% | 23.4% |
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Who owns and runs it
29 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Pc Wcm Opco Holdco LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 3 facilities |
| Des Capital LLC | Adp Of The SNF · Organization | 0% | 28 facilities |
| Flygt, Thomas | Operational/Managerial Control · Individual | 0% | 3 facilities |
| Flygt, Thomas | Adp Of The SNF · Individual | 0% | 3 facilities |
| Greenwood, Emily | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Greenwood, Emily | Adp Of The SNF · Individual | 0% | 1 facilities |
| Hellman, Yosef | Managing Control - Governing Body · Individual | 0% | 19 facilities |
| Hellman, Yosef | Operational/Managerial Control · Individual | 0% | 19 facilities |
| Jrk Investments LLC | Adp Of The SNF · Organization | 0% | 28 facilities |
| Klugman, Jacob | Indirect Ownership Interest · Individual | 0% | 30 facilities |
| Klugman, Jacob | Adp Of The SNF · Individual | 0% | 30 facilities |
| Leverentz, Luanne | Adp Of The SNF · Individual | 0% | 3 facilities |
| Pc Wcm Propco Holdco LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Pc Wcm Topco LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 3 facilities |
| Pc Wcm Topco LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Peace Capital Holdings Ii LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 20 facilities |
| Peace Capital Holdings Ii LLC | Adp Of The SNF · Organization | 0% | 20 facilities |
| Pendleton, Julie | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Pendleton, Julie | Adp Of The SNF · Individual | 0% | 1 facilities |
| Sms 2021 Trust | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 77 facilities |
| Sms 2021 Trust | Adp Of The SNF · Organization | 0% | 77 facilities |
| St. Clare Propco LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Stein, Shalom | Indirect Ownership Interest · Individual | 0% | 87 facilities |
| Stein, Shalom | Managing Control - Governing Body · Individual | 0% | 87 facilities |
| Stein, Shalom | Corporate Officer · Individual | 0% | 87 facilities |
| Stein, Shalom | Trustee Of The SNF · Individual | 0% | 87 facilities |
| Stein, Shalom | Adp Of The SNF · Individual | 0% | 87 facilities |
| Sternbuch, Daniel | Operational/Managerial Control · Individual | 0% | 31 facilities |
| Sternbuch, Daniel | Adp Of The SNF · Individual | 0% | 31 facilities |
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Fire safety
28 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Properly provide smoke detection systems in areas open to corridors.
- D
Install an approved automatic sprinkler system.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Install corridor and hallway doors that block smoke.
- E
Provide properly protected cooking facilities.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems5F
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- D
Meet requirements for the installation and maintenance of electrical systems.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Meet requirements for the installation and maintenance of electrical systems.
Egress4F
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- E
Install proper backup exit lighting.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Miscellaneous3F
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have simulated fire drills held at unexpected times.
- E
Provide properly sized and located linen or trash receptacles.
Services2F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Emergency Preparedness1F
- F
Develop Emergency Preparedness policies and procedures.
Construction1D
- D
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
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Other homes nearby
-
Wisconsin Dells Health Services
Wisconsin Dells, WI · North Shore Healthcare
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 28 min
- Fines
- $0
-
Maplewood of Sauk Prairie
Sauk City, WI
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 15 min
- Fines
- $0
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Ridgeview Terrace Long Term Care
Reedsburg, WI
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 5 h 32 min
- Fines
- $0