With a score of 38/100, Complete Care At Nazareth Llc ranks in the bottom tier of Wisconsin nursing facilities, earning an F grade. CMS data highlights significant concerns that prospective residents and families should thoroughly evaluate.
Staffing levels at Complete Care At Nazareth Llc exceed national averages, with 4.69 total nursing hours per resident per day — compared to the national average of 3.8 hours. RN coverage of 0.91 hours per resident per day also exceeds the national average of 0.7 hours.
Recent CMS inspections identified 25 deficiencies at Complete Care At Nazareth Llc, including 2 classified as serious — among the most concerning citation levels. The most notable finding involved: provide medically-related social services to help each resident achieve the highest possible quality of life..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 4.69 | 3.8 | Above Average |
| Registered Nurses (RN) | 0.91 | 0.7 | Above Average |
| Licensed Practical Nurses (LPN) | 0.74 | 0.7 | Average |
| Certified Nursing Assistants (CNA) | 3.03 | 2.4 | Above Average |
| Weekend Total Nursing | 4.28 | 3.8 | Above Average |
| Weekend RN Hours | 0.72 | 0.7 | Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0745 Severity DProvide medically-related social services to help each resident achieve the highest possible quality of life.Apr 1, 2025 · Quality of Life and Care Deficiencies
- Tag 0804 Severity FEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.Jan 8, 2025 · Nutrition and Dietary Deficiencies
- Tag 0812 Severity FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Jan 8, 2025 · Nutrition and Dietary Deficiencies
- Tag 0689 Severity DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Jan 8, 2025 · Quality of Life and Care Deficiencies
- Tag 0755 Severity DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Jan 8, 2025 · Pharmacy Service 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 | 3.8% | 4.5% | Better |
| Falls with major injury | 4.3% | 3.0% | Worse |
| On antipsychotic medication | 10.6% | 14.5% | Better |
| Urinary tract infections | 1.8% | 2.5% | Better |
| ADL decline (daily activities) | 11.4% | 14.0% | Better |
| Excessive weight loss | 8.0% | 7.5% | Average |
| New/worsened incontinence | 31.1% | 45.0% | Better |
⚠️ Penalties & Fines
2 penalties recorded by CMS
Total fines: $32,443
How This Grade Was Calculated
This facility's grade of F is based on a score of 38 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 2★ → 16 pts (max 40)
- Health Inspection Rating: 2★ → 10 pts (max 25)
- Staffing Rating: 4★ → 16 pts (max 20)
- Quality Measures Rating: 3★ → 9 pts (max 15)
- Penalty deductions: -10 pts
- Fine deductions: -3 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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