Complete Care at Jefferson Meadows LLC
1414 Jefferson St., Baraboo, WI 53913 · Sauk County · 102 certified beds · avg 50 residents/day · certified since Feb 1, 1982
Part of chain: COMPLETE CARE (85 facilities, chain avg rating 3.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jan 31, 2025 · F-0700 · triggered by a complaint
The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Why it matters: Improperly used bed rails can trap or injure residents — in the worst cases, causing serious harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 21, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 27, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 24, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 13, 2025 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 10, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 2, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 13, 2025 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 13, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 13, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 13, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 13, 2025 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| May 13, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| May 13, 2025 | C · Minimal risk, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 31, 2025 | ▲ K · Immediate jeopardy, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Feb 27, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 27, 2023 | E · Potential for harm, repeated | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Feb 27, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Feb 27, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 27, 2023 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Feb 27, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 27, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | J ▲ |
| 2025 | 15 | 2 | K ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $54,326.
| Date | Type | Amount / length |
|---|---|---|
| May 13, 2025 | Fine | $19,135 |
| Jan 31, 2025 | Fine | $35,191 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.45 | 4.29 | 3.95 | bottom 22% in Wisconsin; bottom 34% in the U.S. |
| Registered Nurse hours | 1.06 | 1.01 | 0.69 | top 38% in Wisconsin; top 13% in the U.S. |
| Weekend total nurse staffing | 3.00 | 3.84 | 3.50 | bottom 18% in Wisconsin; bottom 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.86 | 0.68 | 0.48 | top 21% in Wisconsin; top 9% in the U.S. |
| Total nursing staff turnover (%) | 63.6 | 46.9 | 45.8 | bottom 14% in Wisconsin; bottom 11% in the U.S. |
| RN turnover (%) | 55.6 | 39.7 | 42.9 | bottom 27% in Wisconsin; bottom 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.92, RN 1.20, weekend 3.41. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Klugman, Jacob | Individual | Indirect Ownership Interest | NOT APPLICABLE | 02/28/2025 |
| PC WCM Opco Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/28/2025 |
| PC WCM Topco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/28/2025 |
| Peace Capital Holdings II LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/28/2025 |
| SMS 2021 Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 02/28/2025 |
| Stein, Shalom | Individual | Indirect Ownership Interest | NOT APPLICABLE | 02/28/2025 |
| Des Capital LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Flygt, Thomas | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
| Flygt, Thomas | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Greenwood, Emily | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
| Greenwood, Emily | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Hellman, Yosef | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/28/2025 |
| Hellman, Yosef | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
| JRK Investments LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Klugman, Jacob | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Leverentz, Luanne | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| PC WCM Propco Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| PC WCM Topco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Peace Capital Holdings II LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Pendleton, Julie | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Wisconsin Dells Health Services | 9.8 mi | Wisconsin Dells, WI | ★★★☆☆ | 3/5 | |
| Maplewood of Sauk Prairie | 13.9 mi | Sauk City, WI | ★★★☆☆ | 2/5 | |
| Ridgeview Terrace Long Term Care | 14.3 mi | Reedsburg, WI | ★★★★★ | 5/5 | |
| Dove Healthcare - Lodi | 15.0 mi | Lodi, WI | ★★★☆☆ | 3/5 | |
| Sauk Co Health Care Center | 15.6 mi | Reedsburg, WI | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525317.