Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Complete Care at Nazareth LLC

Stoughton, WI · 99 certified beds · Last Life Safety survey April 2, 2026

CMS Certification Number 525681 · first certified January 2005

Ownership

Operated by COMPLETE CARE · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WI

37 citations — more than 95% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 10 citations; the earlier surveys in the window averaged 13.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was April 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 37 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 37 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	37
Median facility in WI	17
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
November 30, 2023	14
January 9, 2025	13
April 2, 2026	10

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0363	Install corridor and hallway doors that block smoke.	3	2026-04-02
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2026-04-02
K-0222	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.	3	2026-04-02
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	3	2026-04-02
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	2	2026-04-02
K-0311	Have an enclosure around a vertical opening shaft.	2	2025-01-09
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2025-01-09
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	2	2025-01-09

What the citations cover

Citations by CMS category

Smoke Deficiencies 16
Egress Deficiencies 7
Services Deficiencies 4
Emergency Preparedness Deficiencies 4
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	16
Egress Deficiencies	7
Services Deficiencies	4
Emergency Preparedness Deficiencies	4
Gas, Vacuum, and Electrical Systems Deficiencies	4
Miscellaneous Deficiencies	1
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 2, 2026 — 10 citations

Citations issued on April 2, 2026
Tag	What the surveyor checks	Status
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (April 27, 2026)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (April 27, 2026)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (April 27, 2026)
K-0222	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.	Deficient, Provider has date of correction (April 27, 2026)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (April 27, 2026)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (April 27, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (April 27, 2026)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (April 27, 2026)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (April 27, 2026)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (April 27, 2026)

January 9, 2025 — 13 citations

Citations issued on January 9, 2025
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (February 3, 2025)
K-0222	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.	Deficient, Provider has date of correction (February 3, 2025)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (February 3, 2025)
K-0311	Have an enclosure around a vertical opening shaft.	Waiver has been granted (February 3, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (February 3, 2025)
K-0331	Construct fire resistant interior walls.	Deficient, Provider has date of correction (February 3, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 3, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 3, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 3, 2025)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (February 3, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (February 3, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (February 3, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 3, 2025)

November 30, 2023 — 14 citations

Citations issued on November 30, 2023
Tag	What the surveyor checks	Status
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (January 25, 2024)
K-0132	Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.	Deficient, Provider has date of correction (December 27, 2023)
K-0222	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.	Deficient, Provider has date of correction (January 12, 2024)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (December 27, 2023)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has no plan of correction
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (December 27, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 25, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 27, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 27, 2023)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (December 27, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (January 25, 2024)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (January 12, 2024)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (January 12, 2024)
K-0912	Have power receptacles that are properly grounded.	Deficient, Provider has date of correction (December 27, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.