Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Jefferson Meadows Llc during CMS and state inspections, most recent first.
Three residents did not receive adequate nutrition and hydration due to the facility's failure to monitor and document fluid and food intake, update care plans and assessments after significant changes in condition, and communicate with the physician or registered dietitian as required. One resident suffered actual harm, including hospitalization for severe dehydration, while two others experienced significant weight loss and inconsistent monitoring of their nutritional needs.
Dietary staff were observed handling food with bare hands and without performing hand hygiene, as well as entering food service areas without required hair restraints. These actions violated facility policy and were confirmed as unacceptable by dietary staff and management.
Surveyors observed that six expired stock antibiotic ointments, including bacitracin zinc and triple antibiotic ointments, were present in the medication room. The DON confirmed these medications were expired and should not have been available, indicating a failure to follow facility policy for medication storage and removal of outdated drugs.
Surveyors identified that multiple residents did not have documentation of MD or NP visits in their medical records, either in the EHR or paper charts. Staff interviews revealed inconsistent access to and retrieval of visit notes, with some staff not regularly checking the EHR and others lacking access altogether. Facility policies requiring tracking and documentation of physician visits were not consistently followed, resulting in incomplete and inaccessible medical records.
The facility did not follow its antibiotic stewardship protocols by failing to verify infection criteria and monitor symptoms and treatment effectiveness for several residents started on antibiotics for UTIs and pneumonia. Required documentation of infection assessment and ongoing monitoring was missing, despite staff stating that such protocols were in place.
The facility did not complete or maintain required PASRR Level I and Level II screenings for two residents with mental health diagnoses. For one resident, no PASRR Level I was found, and for another, a PASRR Level II was missing despite a Level I with a 30-day exemption. The social worker and DON confirmed the absence of necessary documentation and acknowledged that PASRRs should be completed and kept in the medical record.
A resident with severe cognitive impairment was repeatedly observed without meaningful activities, spending most days napping or roaming the halls. Despite a care plan outlining the need for therapeutic recreation and staff support, the facility did not consistently provide individualized activities or adequate documentation of participation, resulting in unmet physical, mental, and psychosocial needs.
A resident with severe cognitive impairment and malnutrition, who was receiving nutrition and medication via G-tube, did not have proper verification of tube placement prior to feeding. Nursing staff checked placement using only air, omitting the required aspiration of gastric contents as outlined in facility policy and the care plan. Both the nursing supervisor and DON confirmed that aspiration should have been performed.
A registered nurse was observed crushing and preparing to administer extended-release Levetiracetam tablets to a resident with epilepsy, contrary to facility policy and manufacturer instructions that prohibit crushing such medications. The nurse assumed all medications should be crushed due to the resident's swallowing difficulties, but the resident's chart did not specify this. The error was identified by surveyors before administration.
Two residents receiving hospice care did not have their current hospice plans of care available to facility staff, despite facility policy requiring coordination and documentation. Staff interviews revealed inconsistent processes for obtaining and reviewing hospice care plans, and documentation was limited to team listings and visit logs without substantive care information. The hospice plans of care were not found in the residents' charts or hospice binders, and staff had to request them from external sources.
A resident with moderate cognitive impairment and a history of trauma was repeatedly subjected to verbal abuse, including yelling and profanity, by her activated POA. Despite multiple incidents witnessed and reported by staff, the facility did not implement or document specific interventions in the care plan or Kardex to prevent further abuse or ensure the resident's safety during visits. Staff awareness of the situation and required actions was inconsistent, and the facility failed to ensure effective measures were in place to protect the resident from ongoing verbal abuse.
Staff failed to immediately intervene when a resident was subjected to alleged verbal abuse by her POA, despite overhearing loud yelling and profanity. The CNA and RN reported the incident to the DON but did not enter the room or ensure the resident's immediate safety. The resident, who had cognitive impairment and was identified as vulnerable to abuse, was found crying after the incident. Staff interviews indicated uncertainty about specific interventions and a lack of immediate protective action during the event.
A resident with moderate cognitive impairment, a history of trauma, and recent bereavement did not have a comprehensive, person-centered care plan that incorporated behavioral health recommendations for grief and trauma support. Despite receiving behavioral health services and having specific interventions recommended by psychology, these were not included in the care plan, and staff were not fully informed of the resident's trauma history.
The facility did not monitor or document water heater and hot water storage tank temperatures as required by its infection prevention and control program, leaving it unable to demonstrate compliance with national standards for minimizing Legionella risk. Interviews with maintenance staff and the administrator confirmed the absence of temperature logs, despite policy requirements and a work order system intended for regular checks. This deficiency had the potential to impact all residents in the facility.
A facility failed to assess the risks of using side rails with air mattresses, leading to a resident's entrapment and subsequent death. The resident, with severe dementia and reduced mobility, was not properly assessed for entrapment risks when their mattress was changed to a Panacea Convertible Mattress with powered alternating-pressure therapy. The facility did not document alternatives to side rails or provide updated risk information to the resident's Health Care Power of Attorney. This oversight resulted in immediate jeopardy findings.
Failure to Ensure Adequate Nutrition and Hydration for Multiple Residents
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for three residents, resulting in one resident experiencing actual harm and two others being placed at risk for more than minimal harm. For one resident with severe dementia, the facility did not total or assess daily fluid intake, failed to accurately assess and document ongoing signs and symptoms of dehydration, and did not update care plans or nutritional assessments after a significant change in condition that led to hospitalization for severe hypernatremia and dehydration. Despite clear evidence of declining intake and physical changes, there was no documentation of interventions attempted or communication with the registered dietitian prior to the hospitalization. Staff interviews confirmed that the resident required assistance and encouragement to eat and drink, but this was not consistently documented or reflected in updated care plans. Another resident experienced significant weight loss, but the facility did not appropriately notify the physician or nurse practitioner, started a nutritional supplement without a physician's order, and failed to monitor the amount of supplement consumed. The dietary assessment for this resident had not been updated in over a year, and there was no comprehensive documentation of calorie, protein, or hydration needs. Staff interviews revealed confusion about the process for supplement administration and tracking, and the resident reported dissatisfaction with the food and lack of snacks. A third resident's fluid intake was not monitored, and the physician was not notified of a severe weight loss of 10% over two weeks. The resident's favorite beverage was not added to the care plan as required by facility policy, and a complete nutrition assessment by the registered dietitian was not conducted. Documentation of fluid intake was inconsistent, and the resident was not consistently offered snacks. Facility policies required systematic assessment, monitoring, and documentation of hydration and nutrition, but these were not followed for the residents reviewed.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
Surveyors observed that dietary staff failed to follow safe and sanitary food handling practices during food preparation and service. Specifically, staff were seen directly touching sausage and the inside lip of fruit cups with their bare hands, without wearing gloves or performing hand hygiene. Additionally, staff entered the kitchen and food service area without wearing required hair restraints while food service was ongoing. These actions were in direct violation of the facility's Food Safety Requirements policy, which mandates the use of gloves, tongs, or other barriers when handling food and requires hair restraints in food preparation and service areas. Interviews with dietary staff and the dietary manager confirmed that these practices were not acceptable and were contrary to established policy.
Expired Antibiotic Ointments Found in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional standards in the medication room. During an observation with the Director of Nursing (DON), six expired stock antibiotic ointments were discovered, including three bacitracin zinc ointments and three triple antibiotic ointments (bacitracin zinc/neomycin sulfate/polymyxin B sulfate), all past their expiration dates. The expired medications were present in the medication storage room, contrary to facility policy and professional guidelines. The facility's policy requires that all medications be stored according to manufacturer recommendations and that discontinued, outdated, or deteriorated medications be routinely inspected and destroyed as appropriate. However, the presence of these expired ointments indicated that the required inspections and removals had not been adequately performed. The DON confirmed during interview that the expired creams should not have been in circulation and verified their expired status.
Failure to Maintain and Document MD/NP Visit Notes in Resident Medical Records
Penalty
Summary
Surveyors found that the facility failed to maintain complete, accurate, and readily accessible medical records for all residents reviewed. Specifically, for 13 residents, there was no documentation of routine or acute visits by medical doctors (MD) or nurse practitioners (NP) in either the electronic health record (EHR) or paper charts. This lack of documentation was discovered during a review of records and interviews with staff, who confirmed that visit notes were not regularly obtained or filed in the residents' records. Facility policies require licensed nurses to track physician visit due dates, remind physicians to document visits, and for the Director of Nursing or designee to conduct monthly audits for timeliness. Additionally, all assessments, observations, and services provided are to be documented in accordance with state law and facility policy. Despite these policies, staff interviews revealed inconsistent practices regarding access to and retrieval of MD/NP visit notes. Some staff had access to the EHR but did not check it regularly, while others lacked access entirely and relied on supervisors for information. Further interviews with the Nursing Supervisor, RNs, LPNs, the Nursing Home Administrator, and Medical Records staff indicated a lack of clarity and consistency in responsibility for obtaining and tracking MD/NP visit documentation. The Medical Records staff acknowledged that a comprehensive review had not been conducted recently, and that obtaining visit notes had not been consistently performed. As a result, the facility did not have the required MD/NP visit notes readily accessible in the health records for the residents reviewed.
Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
The facility failed to follow its own antibiotic stewardship program and standards of practice for monitoring antibiotic use, as evidenced by the lack of verification that infection criteria were met and insufficient monitoring of symptoms and treatment effectiveness for several residents started on antibiotics. The policy required nursing staff to assess residents suspected of infection, verify infection criteria (such as McGeer's Criteria), and document both the initiation and ongoing monitoring of antibiotic therapy, including an antibiotic timeout within 48-72 hours. However, for multiple residents, there was no documentation that these steps were followed. One resident with a history of cystitis and chronic kidney disease was started on antibiotics for urinary symptoms, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of treatment during and after the antibiotic course. Another resident with encephalopathy and failure to thrive was prescribed antibiotics for a UTI, but there was no documentation of infection criteria assessment or monitoring of symptoms and treatment response. Similarly, a resident with multiple sclerosis and overactive bladder was started on antibiotics for a UTI based on staff observations and lab results, but again, there was no documentation of infection criteria review or monitoring of symptoms before or after starting antibiotics. Additionally, a resident with chronic obstructive pulmonary disease and paroxysmal atrial fibrillation was treated for pneumonia after a chest x-ray, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of antibiotic treatment. Interviews with facility staff confirmed that while McGeer's Criteria were referenced, there was no documentation of their use, and no evidence of required monitoring or assessment was found in the records. The facility's failure to document these critical steps led to the deficiency.
Failure to Complete and Document Required PASRR Screenings
Penalty
Summary
The facility failed to follow the required Preadmission Screening and Resident Review (PASRR) process for two residents. For one resident with diagnoses including dementia, depression, and mood disorder, there was no documentation of a PASRR Level I screening being completed prior to admission, as required by facility policy and Medicaid rules. The social worker confirmed that no PASRR documentation could be found for this resident, indicating that the initial screening step was missed. For another resident with diagnoses such as delusional disorders, restlessness, and agitation, a PASRR Level I was submitted with a 30-day exemption, but there was no documentation of a required PASRR Level II evaluation. The social worker was unable to provide evidence that the Level II evaluation had been completed, and the Director of Nursing confirmed that PASRRs should be completed timely and maintained in the resident's medical record. These lapses demonstrate that the facility did not ensure the appropriate PASRR steps were followed and documented for residents with mental disorders or intellectual disabilities.
Failure to Provide Individualized Activity Program for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of a resident with severe cognitive impairment. Observations over multiple days showed the resident sitting in a hallway, often staring at a wall, with no meaningful activities offered. Documentation from January to May indicated the resident primarily napped or roamed the halls, with minimal participation in activities such as family visits, animal therapy, or group events. The resident's care plan specified the need for therapeutic recreation, including weekly one-on-one visits, group activities, and the provision of comfort items like baby dolls, but these interventions were not consistently implemented. Interviews with staff revealed that the resident was unable to structure her own leisure time and required staff support to attend activities. Staff acknowledged that activity documentation lacked details on duration, participation level, and enjoyment, and that alternative activities were not offered if the resident was napping during scheduled events. The activity director confirmed that the resident enjoyed sensory activities, music, and outdoor time, but required assistance to access these opportunities. Despite these identified needs and preferences, the facility did not ensure an ongoing, individualized activity program for the resident.
Failure to Properly Verify G-Tube Placement Prior to Feeding
Penalty
Summary
A deficiency occurred when a resident receiving nutrition and medication via a G-tube did not receive appropriate treatment and services as required by facility policy and the resident's care plan. The facility's policy and the resident's care plan both required that tube placement be verified before each feeding and medication administration by both auscultation and aspiration of gastric contents. However, during observation, a registered nurse checked the G-tube placement using only air and did not aspirate gastric contents prior to administering the tube feeding. The nurse acknowledged in an interview that she typically does not aspirate gastric contents, despite knowing it is required. Further interviews with the nursing supervisor and the director of nursing confirmed that their expectation is for staff to both listen for air flow and aspirate gastric contents when checking G-tube placement. The resident involved had significant cognitive impairment, severe protein-calorie malnutrition, and was at risk for complications related to tube feeding. The failure to follow established protocols for verifying tube placement and aspirating gastric contents prior to feeding constituted a deficiency in care for this resident.
Crushing of Extended-Release Medication by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) prepared to administer medications to a resident diagnosed with generalized idiopathic epilepsy and epileptic syndromes. The RN was observed crushing seven medications, including two tablets of Levetiracetam ER (an extended-release anticonvulsant), despite facility policy and manufacturer instructions that specifically prohibit crushing extended-release medications. The facility's policy requires medications to be administered as ordered and in accordance with manufacturer specifications, including not crushing medications labeled as 'do not crush.' The RN admitted to crushing the Levetiracetam ER tablets based on an assumption that the resident, who had a history of stroke and difficulty swallowing, required all medications to be crushed. The resident's chart did not specify administration instructions for these medications. The error was identified by surveyors before the medications were administered, and the RN acknowledged that she would not have caught the error without their intervention.
Failure to Ensure Hospice Plan of Care Availability and Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice providers for two residents receiving hospice care. For both residents, the current hospice plan of care was not available to facility staff, despite the facility's policy requiring coordination and documentation of hospice interventions. Interviews with nursing staff, including the RN, Nursing Supervisor, MDS/Infection Preventionist, and DON, revealed inconsistent understanding and execution of processes for obtaining, reviewing, and integrating the hospice plan of care into the facility's records. Staff were either unaware of the location of the hospice plan of care or stated that it was not provided or reviewed, and documentation in the hospice communication binder was limited to team listings and visit logs without substantive care information. One resident had diagnoses including corticobasal degeneration, Alzheimer's disease, and was receiving palliative care. The facility's care plan referenced hospice involvement and directed staff to see the hospice plan of care, but this document was not found in the resident's chart or the hospice binder. Staff interviews confirmed that the hospice plan of care was not reviewed or integrated into the facility's care planning process, and the designated hospice liaison did not review the hospice plan of care. The second resident, with a history of hemorrhagic stroke, quadriplegia, and vascular dementia, was also receiving hospice care. The resident's care plan included interventions to coordinate with hospice and notify them of changes, but the hospice plan of care was not present in the paper chart, electronic medical record, or hospice binder. Facility staff had to request the hospice plan of care from an external electronic health record, indicating a lack of immediate access and integration. The DON confirmed the expectation that the facility should review and align the hospice plan of care with the facility's plan, but this was not occurring.
Failure to Protect Resident from Repeated Verbal Abuse by POA
Penalty
Summary
A resident with moderate cognitive impairment and a history of childhood abuse was subjected to repeated verbal abuse by her activated Power of Attorney (POA) while at the facility. The POA was reported to have yelled, used profanity, and displayed aggressive behavior toward the resident on multiple occasions, including incidents where staff overheard loud, profane language and observed the resident crying. Despite these events, the facility did not implement or document specific interventions to prevent further verbal abuse or to ensure the resident's safety during visits from the POA. The resident's care plan and Kardex did not include any interventions or increased monitoring related to the POA, even though the facility's policies defined verbal abuse and allowed for visitation restrictions in cases of emotionally harmful behavior. Staff interviews revealed a lack of awareness regarding any interventions or special precautions for the resident when the POA was present. While some staff were aware of a memo at the nurse's station instructing them to report any yelling by the POA, this information was not consistently communicated to all staff, including new or agency staff, and was not reflected in the resident's care documentation. Multiple staff members, including CNAs, nurses, and support staff, acknowledged hearing or being aware of the POA's verbally abusive behavior toward the resident. However, there was inconsistency in staff responses, with some not intervening or being unclear about the appropriate actions to take. The facility leadership chose not to document interventions in the care plan or Kardex, citing concerns about the POA's access to these documents. As a result, the facility failed to ensure that effective measures were in place to protect the resident from ongoing verbal abuse by the POA.
Failure to Immediately Intervene During Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to immediately intervene when staff heard alleged verbal abuse directed at a resident by her power of attorney (POA). Staff, including a CNA and an RN, overheard loud yelling and profanity coming from the resident's room, with the POA using explicit language and raising her voice. The CNA reported the incident to the nurse, who then notified the Director of Nursing (DON), but neither staff member entered the room or directly intervened to ensure the resident's immediate safety at the time the abuse was occurring. The resident involved had a history of cognitive impairment, including dementia and mood disorders, and was identified as vulnerable to abuse in her care plan. When the DON and Nursing Home Administrator (NHA) entered the room, the POA's behavior de-escalated, but the resident was observed crying. The resident stated she felt safe with her POA and wanted visits to continue, but staff and social services confirmed that this was not the first time the POA had yelled at the resident. Despite the facility's abuse prevention policy requiring immediate protection and intervention for residents at risk, staff did not act promptly to protect the resident during the incident. Staff interviews revealed that while there had been recent education on abuse reporting, the CNA and RN did not physically check on the resident or intervene during the altercation, instead relying on reporting the incident up the chain of command. The care plan and other documentation did not include specific interventions for staff to follow in such situations, and staff were uncertain about what measures were in place to keep the resident safe during and after such incidents.
Failure to Develop Person-Centered Care Plan for Behavioral Health Needs
Penalty
Summary
A deficiency was identified when the facility failed to comprehensively assess and develop a person-centered care plan for a resident experiencing ongoing grief and sadness following the recent loss of her son, as well as past trauma. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and other behavioral and emotional disorders, was found to be moderately cognitively impaired and had an activated power of attorney. Despite receiving behavioral health services and having a documented history of significant trauma and recent bereavement, the facility did not incorporate recommended interventions from behavioral health professionals into the resident's care plan. The resident's trauma screening assessment revealed a history of physical and sexual abuse, life-threatening illness, severe human suffering, and the sudden, unexpected death of someone close. A psychology appointment documented maladaptive behavioral symptoms, emotional distress, and specific recommendations for care, such as increasing positive emotions, integrating faith-based support, encouraging socialization, and providing validation during episodes of grief. However, these recommendations were not reflected in the resident's comprehensive care plan or Kardex, which only included general statements about encouraging activity participation and observational behavior monitoring. Interviews with facility staff, including the Nursing Home Administrator and Director of Social Services, confirmed that the recommended interventions from behavioral health were not care planned and that staff were not fully aware of the specifics of the resident's trauma. Observations showed the resident was tearful and withdrawn, and while she reported some support from nursing staff, the lack of a comprehensive, individualized care plan addressing her grief and trauma constituted a failure to provide necessary behavioral health care and services.
Failure to Monitor Water Heater Temperatures per Infection Control Policy
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required by policy and national standards. Specifically, the facility did not monitor or document the temperature of the water heater (WH) or hot water storage tank (HWT) as outlined in their Water Management Program. The program required that water heater and storage tank outlet temperatures be maintained at or above 140 degrees Fahrenheit to prevent the growth of Legionella and other waterborne pathogens. Interviews with the Maintenance Director and Maintenance Tech revealed that while there was a work order in the maintenance management system to check water temperatures monthly, no records or logs of temperature readings could be found. The new Maintenance Director confirmed that there was no documented monitoring of the WH or HWT temperatures. Further, the Nursing Home Administrator acknowledged that a previous maintenance director had implemented a robust plan for temperature testing, but no documentation could be produced to verify ongoing monitoring or compliance with the facility's water management protocols. The lack of documented temperature monitoring meant the facility could not demonstrate that control measures were being followed to minimize the risk of Legionella and other pathogens, as required by their infection prevention and control policy and national guidelines. This deficiency had the potential to affect all 48 residents residing in the facility.
Failure to Assess Risks of Side Rails with Air Mattresses
Penalty
Summary
The facility failed to ensure that alternatives were tried before installing and utilizing side rails for residents, particularly those using an air mattress. This oversight was evident in the case of a resident who was admitted with severe dementia, reduced mobility, osteoporosis, and cerebrovascular disease. The facility implemented the use of side rails without assessing the risks associated with combining them with an air mattress, which increases the risk of entrapment. The resident became entrapped in the side rail, resulting in multiple fractures and subsequently passed away the following day. The facility did not conduct a proper assessment for entrapment risks when changing the resident's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy. Additionally, the facility failed to provide new risk and benefit information to the resident's Health Care Power of Attorney when the mattress was changed. The facility's Bed System Measurement Device, which is not recommended for use with alternating air mattresses, was used without proper documentation, and quarterly bed/side rail measurement tests were not completed as per facility policy. The deficiency was further highlighted by the facility's failure to document any alternatives attempted before utilizing bed rails for other residents. The facility did not provide evidence of alternative interventions being tried prior to the installation of bed rails for other residents using similar air mattresses. This lack of assessment and documentation contributed to the finding of immediate jeopardy, as the facility did not recognize the increased risk of entrapment posed by the combination of side rails and air mattresses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baraboo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wisconsin Dells Health Services | 9.7 mi | ★★★★★ | 6 | 0 |
| Maplewood Of Sauk Prairie | 13.9 mi | ★★★★★ | 14 | 0 |
| Ridgeview Terrace Long Term Care | 14.3 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - Lodi | 15 mi | ★★★★★ | 11 | 0 |
| Sauk Co Health Care Center | 15.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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