Complete Care At Jefferson Meadows Llc
Complete Care at Jefferson Meadows LLC in Baraboo, WI — inspection on May 13, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to the CDC Water Management Toolkit . monitor to ensure control measures are performing as designed.
Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value.
Per Centers for Disease Control and Prevention (CDC), 3/15/24 documents, in part: .Cold water guidance: Store and circulate cold water at temperatures below 77 F, although Legionella may grow at temperatures as low as 68 F (20 C).
Hot water guidance: Store hot water at temperatures above 140 F (60 C).
Ensure hot water in circulation doesn't fall below 120 F (49 C) and recirculate hot water continuously, if possible .
Example 1
On 5/13/25 at 7:32 AM, Surveyor interviewed MDir M (Maintenance Director) and MntT N (Maintenance Tech) and asked about how the facility monitors the WH and HWT outlet temperatures.
MntT N stated 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. MDir M stated there is a work order in the maintenance management computer system assigned for the 15th day of each month which states to check multiple locations for water temperature readings (must be between 110-115 degrees, document finding.). MDir M stated that MDir M has been unable to locate a report of any documented temperature readings.
Surveyor asked if there was monitoring of the water temperature at the WH or HWT. MDir M stated no, there are no documented temperatures.
Of note, 140 degrees is the temperature required to prevent Legionella.
On 5/13/25 at 8:24 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about temperature testing of the water heater outlet. NHA A stated that the past maintenance director had put a robust plan into place and NHA A believed that there had been testing at the boiler.
Surveyor asked NHA A if documentation of temperature testing would be expected. NHA stated yes.
The facility was not able to provide documentation of monitoring the temperature of the water heater or hot water storage tank to show they're monitoring their control measures per their water management plan.
525317
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525317 B.
Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Clare Care and Rehab Center 1414 Jefferson St Baraboo, WI 53913
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.