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63/100Complete Care at Nazareth LLC Inspection Report, Violations & Safety Grade (Stoughton, Wisconsin)
814 Jackson St., Stoughton, Wisconsin 53589
Phone: 6088736448
CMS Overall:2/5
Overview & Bed Count
Certified Beds
99
Avg Residents/Day
63.8
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Dane
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing4/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.80 | 0.98 | -0.19 |
| Total Nurse Hours per Resident per Day | 5.32 | 4.25 | +1.07 |
| CMS Staffing Rating | 4/5 | 3.7/5 | - |
| Nursing Staff Turnover | 56.7% | 46.7% | - |
Health Citation History
27 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2026-06-10 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | F – Moderate Harm Potential |
| 2026-06-10 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2026-04-02 | Nutrition and Dietary Deficiencies | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | F – Moderate Harm Potential |
| 2026-04-02 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2026-04-02 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2026-04-02 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2026-04-02 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | E – Moderate Harm Potential |
| 2026-04-02 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2026-04-02 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2026-04-02 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2026-04-02 | Pharmacy Service Deficiencies | 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 – Moderate Harm Potential |
| 2025-04-02 | Quality of Life and Care Deficiencies | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D – Moderate Harm Potential |
| 2025-01-09 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F – Moderate Harm Potential |
| 2025-01-09 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-01-09 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2025-01-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-01-09 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-01-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-09-30 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2023-11-30 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2023-11-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-11-30 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2023-11-30 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2023-11-30 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-11-30 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2023-11-30 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
Fire Safety Citation History
37 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-02 | Emergency Preparedness Deficiencies | Develop a communication plan. | F – Moderate Harm Potential |
| 2026-04-02 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2026-04-02 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2026-04-02 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-04-02 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2026-04-02 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2026-04-02 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2026-04-02 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2026-04-02 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2026-04-02 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2025-01-09 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2025-01-09 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-01-09 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2025-01-09 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2025-01-09 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | E – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Construct fire resistant interior walls. | E – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | E – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2025-01-09 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2025-01-09 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2023-11-30 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | F – Moderate Harm Potential |
| 2023-11-30 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2023-11-30 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-11-30 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2023-11-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | F – Moderate Harm Potential |
| 2023-11-30 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2023-11-30 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2023-11-30 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | E – Moderate Harm Potential |
| 2023-11-30 | Construction Deficiencies | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | D – Moderate Harm Potential |
| 2023-11-30 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | D – Moderate Harm Potential |
| 2023-11-30 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2023-11-30 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-11-30 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2023-11-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | D – Moderate Harm Potential |
Total Penalties & Fines
$41,952
Total Fine Amount (CMS)
2
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-06-10 | Fine | $26,310 | - |
| 2024-09-30 | Fine | $15,642 | - |
| 2024-09-30 | Payment Denial | - | 20 days starting 2024-10-22 |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Stoughton area at no cost.
Find Safe, Vetted Facilities Near Stoughton
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.