CAPITOL LAKES HEALTH CENTER
333 W MAIN ST, MADISON, WI 53703 · CCN 525305
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★☆ 4
- Staffing
- ★★★★★ 5
Facility
- Ownership type
- Non profit - Corporation
- Certified beds
- 49
- Avg residents/day
- 27.7
- Phone
- 6082832000
Inspection history vs Wisconsin & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Wisconsin avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-11-06 | 8 | 9.8 | 9.5 | -1.8 better |
| 2 | 2023-10-05 | 4 | 9.2 | 9.8 | -5.2 better |
| 3 | 2022-08-11 | 10 | 8.3 | 9.3 | +1.7 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 5 |
| Nutrition and dietary | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 7.79 | 47.6% |
| RN staffing (reported) | 2.02 | 20.0% |
| Total nurse staffing (adjusted) | 7.67 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Chain
- Chain
- PACIFIC RETIREMENT SERVICES
- Facilities in chain
- 10
- Chain avg overall
- 4.60 / 5
Inspection citations (22)1 actual harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- EF0687Provide appropriate foot care.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- FF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2024-11-06 · Health · corrected 2024-12-06
Potential for more than minimal harm
- DF0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.2023-10-05 · Health · corrected 2023-11-03
Potential for more than minimal harm
- DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2023-10-05 · Health · corrected 2023-11-03
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-10-05 · Health · corrected 2023-11-03
Potential for more than minimal harm
- FF0809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.2023-10-05 · Health · corrected 2023-11-03
Potential for more than minimal harm
- GF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2023-06-21 · Health · corrected 2023-07-18
Actual harm
- DF0697Provide safe, appropriate pain management for a resident who requires such services.2023-06-21 · Health · corrected 2023-07-18
Potential for more than minimal harm
- DF0554Allow residents to self-administer drugs if determined clinically appropriate.2022-08-11 · Health · corrected 2022-09-09
Potential for more than minimal harm
- DF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2022-08-11 · Health · corrected 2022-09-09
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2022-08-11 · Health · corrected 2022-09-09
Potential for more than minimal harm
- DF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2022-08-11 · Health · corrected 2022-09-09
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-08-11 · Health · corrected 2022-09-09
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2022-08-11 · Health · corrected 2022-09-09
Potential for more than minimal harm
- BF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-08-11 · Health · corrected 2022-09-09
Potential for minimal harm
- DF0880Provide and implement an infection prevention and control program.2022-08-11 · Health · corrected 2022-09-08
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| PACIFIC RETIREMENT SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2008-04-01 |
| DREW, SALLY | Individual | CORPORATE DIRECTOR | — | 2016-10-10 |
| BISHOP, RICHARD | Individual | CORPORATE OFFICER | — | 2021-10-01 |
| CENTER, SUE | Individual | CORPORATE OFFICER | — | 2017-06-21 |
| JOHANNSEN, STEPHEN | Individual | CORPORATE OFFICER | — | 2019-01-16 |
| NORRBOM, CLAY | Individual | CORPORATE OFFICER | — | 2017-11-17 |
| PETERSON, HARRY | Individual | CORPORATE OFFICER | — | 2017-06-21 |
| SHOLTY, ERIC | Individual | CORPORATE OFFICER | — | 2018-05-27 |
| CONROY, TIMOTHY | Individual | W-2 MANAGING EMPLOYEE | — | 2009-03-23 |
| KBC BANK NV | Organization | 5% OR GREATER SECURITY INTEREST | — | 2022-01-01 |
| LAPIS MUNICIPAL OPPORTUNITIES FUND III LP | Organization | 5% OR GREATER SECURITY INTEREST | — | 2022-01-01 |
Other facilities in MADISON
| Name | Overall | Beds |
|---|---|---|
| HEBRON OAKS | ★★★☆☆ | 70 |
| OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER | ★★☆☆☆ | 40 |
| OAK PARK NURSING AND REHAB CENTER | ★☆☆☆☆ | 100 |
| MADISON HEALTH AND REHABILITATION CENTER | — | 83 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.