Complete Care at Nazareth LLC
Open-data reference.
Complete Care at Nazareth LLC is a for profit - corporation facility in Stoughton, WI with 99 certified beds and a 2-star overall CMS rating. The facility has 25 deficiency records on file. Total penalties: $32K.
814 Jackson St., Stoughton, WI 53589
Phone: 6088736448
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525681
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 99
- Residents
- 65
- In Hospital
- No
- County
- Dane
- Last Inspection
- Jan 9, 2025
Staffing Data
- RN Hours
- 0.91 (nat'l avg: 0.68)
- LPN Hours
- 0.74
- CNA Hours
- 3.03
- Total Nursing Hours
- 4.69 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 53.5%
- RN Turnover
- 60.0%
What the CMS Record Reveals About Complete Care at Nazareth LLC
Complete Care at Nazareth LLC operates 99 certified beds in Stoughton, WI with approximately 65 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (4★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 25 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $32K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.69 total nursing hours per resident day (national average 3.89), with RN coverage at 0.91 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Complete Care at Nazareth LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 53.5%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (25 most recent)
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 21, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 3, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 3, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 3, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 3, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Feb 3, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 3, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 11, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Dec 27, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 27, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 27, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 27, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 27, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2023
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Dec 27, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 4, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 16, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 4, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 4, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 4, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Mar 27, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 27, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 12, 2022
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 12, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 12, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 11.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 8.0% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.8% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.3% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 96.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 86.5% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 27.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 9.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 84.3% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.8% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 31.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.6% | Yes |
Penalty History 2 penalties totaling $32K
| Date | Type | Amount |
|---|---|---|
| Sep 30, 2024 | Fine | $16K |
| Sep 30, 2024 | Payment Denial | - |
| Jul 20, 2023 | Fine | $17K |
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County Health Data
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Frequently Asked Questions
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Does Complete Care at Nazareth LLC have any deficiencies on record?
Has Complete Care at Nazareth LLC received any fines or penalties?
Who owns Complete Care at Nazareth LLC?
When was Complete Care at Nazareth LLC last inspected?
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.