D

Complete Care at Jefferson Meadows LLC

1414 Jefferson St., Baraboo, WI 53913
Score: 48 / 100

CMS data shows Complete Care At Jefferson Meadows Llc earning a D grade with a score of 48/100, placing it below most facilities in Wisconsin. Prospective residents and families should carefully review the specific areas of concern detailed below.

Staffing levels at Complete Care At Jefferson Meadows Llc exceed national averages, with 4.20 total nursing hours per resident per day — compared to the national average of 3.8 hours. RN coverage of 1.06 hours per resident per day also exceeds the national average of 0.7 hours.

Recent CMS inspections identified 22 deficiencies at Complete Care At Jefferson Meadows Llc, including 2 classified as serious — among the most concerning citation levels. The most notable finding involved: provide enough food/fluids to maintain a resident's health..

Score Breakdown

Overall CMS Rating 24 / 40 pts
3 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 16 / 20 pts
4 ★ staffing rating
Quality Measures 15 / 15 pts
5 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 4.20 3.8 Above Average
Registered Nurses (RN) 1.06 0.7 Above Average
Licensed Practical Nurses (LPN) 0.42 0.7 Below Average
Certified Nursing Assistants (CNA) 2.71 2.4 Above Average
Weekend Total Nursing 3.65 3.8 Average
Weekend RN Hours 0.75 0.7 Average

🔍 Inspection & Deficiency History

22
Total Deficiencies
May 12, 2025
Most Recent Inspection
⚪ 1 Minor 🟠 19 Moderate 🔴 2 Serious
View recent deficiencies (5 shown)
  • Tag 0692 Severity G
    Provide enough food/fluids to maintain a resident's health.
    May 12, 2025 · Quality of Life and Care Deficiencies
  • Tag 0812 Severity F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    May 12, 2025 · Nutrition and Dietary Deficiencies
  • Tag 0761 Severity E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologi
    May 12, 2025 · Pharmacy Service Deficiencies
  • Tag 0842 Severity E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standar
    May 12, 2025 · Resident Assessment and Care Planning Deficiencies
  • Tag 0881 Severity E
    Implement a program that monitors antibiotic use.
    May 12, 2025 · Infection Control Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 1.6% 4.5% Better
Falls with major injury 0.0% 3.0% Better
On antipsychotic medication 9.5% 14.5% Better
Urinary tract infections 2.6% 2.5% Average
ADL decline (daily activities) 19.3% 14.0% Worse
Excessive weight loss 4.4% 7.5% Better
New/worsened incontinence 37.5% 45.0% Better

⚠️ Penalties & Fines

2 penalties recorded by CMS

Total fines: $73,275

How This Grade Was Calculated

This facility's grade of D is based on a score of 48 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 3★ → 24 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 4★ → 16 pts (max 20)
  • Quality Measures Rating: 5★ → 15 pts (max 15)
  • Penalty deductions: -10 pts
  • Fine deductions: -7 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
102
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
May 12, 2025
Deficiencies (Cycle 1)
14