D67

Complete Care at Jefferson Meadows LLC

Grade D 67/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
2/5
Health Insp.
1/5
Quality
5/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

102

Ownership

For profit - Limited Liability company

Total Fines

$109,565

Last Survey

N/A

1414 Jefferson St., Baraboo, WI 53913
6083564838

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.02h
LPN
0.40h
CNA
2.60h
Total
4.02h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

PC WCM OPCO HOLDCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Feb 2025

100%

PC WCM TOPCO LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2025

PEACE CAPITAL HOLDINGS II LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2025

SMS 2021 TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2025

FLYGT, THOMAS

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2025

GREENWOOD, EMILY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2025

HELMAN, YOSEF

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2025

PENDLETON, JULIE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2025

STERNBUCH, DANIEL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2025

STEIN, SHALOM

IndividualCORPORATE OFFICERSince Feb 2025

Penalties & Fines (3)

$109,565total fines
DateTypeDescriptionAmount
May 13, 2025Fine$19,135
Jan 31, 2025Fine$54,140
Feb 27, 2023Fine$36,290

Health Inspection Deficiencies (22)

May 13, 2025Health14 deficiencies1 severe
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Jun 10, 2025
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Jun 10, 2025
0692GActual harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Jun 10, 2025
0693DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Jun 10, 2025
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Jun 10, 2025
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Jun 10, 2025
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Jun 10, 2025
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 10, 2025
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Jun 10, 2025
0880CNo harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 10, 2025
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 10, 2025
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 10, 2025
0740DMinimal harm, Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Corrected Jun 10, 2025
0881EMinimal harm, Pattern

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Jun 10, 2025
January 31, 2025Health1 deficiency1 severe
0700KImmediate jeopardy, Pattern

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.

Quality of Life and Care Deficiencies

Corrected Feb 21, 2025
February 27, 2023Health7 deficiencies1 severe
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Mar 24, 2023
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Mar 24, 2023
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Mar 13, 2023
0604EMinimal harm, Pattern

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 13, 2023
0686JImmediate jeopardy, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 24, 2023
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Mar 24, 2023
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Mar 24, 2023

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Frequently Asked Questions

What is the CareGrader rating for Complete Care at Jefferson Meadows LLC?

Complete Care at Jefferson Meadows LLC in Baraboo, Wisconsin has a CareGrader grade of D (Below Average), with a composite score of 66.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Complete Care at Jefferson Meadows LLC?

Complete Care at Jefferson Meadows LLC has an overall CMS star rating of 2 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Complete Care at Jefferson Meadows LLC have?

Complete Care at Jefferson Meadows LLC has 22 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has Complete Care at Jefferson Meadows LLC been fined?

Yes. Complete Care at Jefferson Meadows LLC has $109,565 in total fines from CMS enforcement actions across 3 penalties.

How many beds does Complete Care at Jefferson Meadows LLC have?

Complete Care at Jefferson Meadows LLC has 102 certified beds with approximately 49 current residents (48% occupancy). The facility is located at 1414 Jefferson St., Baraboo, Wisconsin 53913. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.