St Clare Care: Water Safety, Antibiotic Failures - WI
At St Clare Care and Rehab Center on Jefferson Street, federal inspectors discovered in May that staff had lost track of a basic safety protocol designed to protect residents from waterborne pathogens that can cause severe pneumonia and death.
The Centers for Disease Control requires nursing homes to store hot water above 140 degrees Fahrenheit to prevent Legionella growth. But when surveyors asked maintenance director M about monitoring, he admitted the facility had no documented temperatures from their water heater or hot water storage tank.
"The last maintenance director had done some form of temperature testing, prior to leaving employment about a month ago, but no record logs had been found," maintenance tech N told inspectors on May 13.
The maintenance director showed surveyors a computer work order scheduled for the 15th of each month instructing staff to check water temperatures at multiple locations. The readings were supposed to fall between 110-115 degrees and be documented. But no reports existed.
"MDir M has been unable to locate a report of any documented temperature readings," the inspection report states.
Administrator A believed the previous maintenance director "had put a robust plan into place" and thought testing had been happening at the boiler. When asked whether documentation would be expected, the administrator said yes.
The water management failure was just one problem inspectors found. Staff were also prescribing antibiotics to residents without following proper protocols to verify infections actually met medical criteria.
Four residents received antibiotic treatment without adequate documentation that they met established infection standards or monitoring of whether the drugs were working.
Antibiotics Without Evidence
R300 arrived at the emergency room on April 8 complaining of painful urination that had lasted about 24 hours. Her temperature was normal at 97.5 degrees. The emergency provider noted that "dysuria is really the only symptom at this time" but decided it was "reasonable to send her home with outpatient antibiotics."
The facility started her on Cefdinir for what they labeled a urinary tract infection. But established medical criteria require multiple symptoms plus laboratory confirmation for a UTI diagnosis. R300 had only one symptom and no documented lab results.
When R300 developed new urinary symptoms on April 25, progress notes show a three-day gap in monitoring. A nurse wrote on April 25 that the resident complained of burning with urination and nausea, with symptoms lasting "3-4 days." The next documented assessment wasn't until April 28, when staff noted "burning, blood in urine" and requested treatment.
She received a second antibiotic, Cefprozil, but again without documented verification that her condition met infection criteria or monitoring of treatment effectiveness.
R42 was prescribed Cefdinir in April after a provider noted the resident had "fever" and became "less somnolent" with fever-reducing medication. The provider specifically noted that a different antibiotic "is generally not recommended for complex or complicated UTIs (for example fever, somnolence)."
Despite the provider's concern about complicated infection symptoms, facility staff provided no documentation showing they verified the infection met established criteria or monitored the resident's response to treatment.
R16, who has multiple sclerosis and bladder dysfunction, was started on Macrobid after staff observed "frequency, incontinence, and foul-smelling urine." A provider noted the resident "denies urinary changes" but had a history of life-threatening sepsis from previous UTIs.
The resident received not one but two courses of the same antibiotic. The first five-day course was discontinued on March 31, then immediately restarted the same day for another week. No documentation explained why the first course was stopped or why a second was needed.
Pneumonia Treatment Gaps
R11, who depends on supplemental oxygen, developed rapid breathing and abnormal lung sounds on February 11. Her respiratory rate hit 38 breaths per minute, well above normal, and nurses heard "coarse crackles" in her right lung base.
A chest X-ray showed pneumonia, and she was started on Levofloxacin. But staff provided no documentation of monitoring her symptoms during treatment or verifying the infection met pneumonia criteria, which require chest imaging plus specific respiratory and constitutional symptoms.
The facility's own antibiotic stewardship policy, updated in April 2025, requires staff to "assess residents who are suspected to have an infection" and "monitor response to antibiotics" to determine if treatment should continue or be adjusted. The policy specifically calls for "antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response."
Infection preventionist D told inspectors that McGeer's Criteria, the established medical standards for diagnosing infections in long-term care, hadn't been verified for any of the four residents. When residents were prescribed antibiotics in emergency rooms or admitted already on antibiotics, D said, "McGeer's is not verified by the facility."
Director of nursing B told inspectors that staff were expected to monitor residents with new symptoms "for at least 72 hours or through course of antibiotic/wellness" and that such monitoring should be documented. B also confirmed that McGeer's Criteria should be documented when determining infections.
But for all four residents, D admitted to inspectors: "no documentation was noted" of symptom monitoring or treatment effectiveness after antibiotics were started.
The inspection found that residents received multiple courses of antibiotics, some lasting over a week, without basic safeguards to ensure the drugs were necessary or working. Meanwhile, the facility's water safety monitoring had completely lapsed, leaving residents potentially exposed to waterborne pathogens that could cause the very respiratory infections staff were treating with inadequately supervised antibiotics.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Jefferson Meadows LLC from 2025-05-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
Complete Care at Jefferson Meadows LLC in Baraboo, WI was cited for violations during a health inspection on May 13, 2025.
The Centers for Disease Control requires nursing homes to store hot water above 140 degrees Fahrenheit to prevent Legionella growth.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.