Starfile / Wisconsin

Complete Care at Maple Grove LLC

3401 Maple Grove Dr., Madison, WI 53719 · CCN 525276

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$95,303

Number of fines

5

Number of penalties

7

Payment denials

2

Chain

Chain

COMPLETE CARE

Facilities in chain

85

Chain avg overall

3.20 / 5

Inspection citations (70)2 immediate jeopardy5 actual harm

1. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-29 · Health · corrected 2025-08-12

   Potential for more than minimal harm

2. EF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

3. DF0554Allow residents to self-administer drugs if determined clinically appropriate.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

4. DF0585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

5. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

6. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

7. DF0660Plan the resident's discharge to meet the resident's goals and needs.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

8. DF0675Honor each resident's preferences, choices, values and beliefs.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

9. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-05-05 · Health · corrected 2025-06-09

   Potential for more than minimal harm

10. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-05-05 · Health · corrected 2025-06-09

    Potential for more than minimal harm

11. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-05 · Health · corrected 2025-06-09

    Actual harm

12. DF0697Provide safe, appropriate pain management for a resident who requires such services.2025-05-05 · Health · corrected 2025-06-09

    Potential for more than minimal harm

13. EF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2025-05-05 · Health · corrected 2025-06-09

    Potential for more than minimal harm

14. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-05-05 · Health · corrected 2025-06-09

    Potential for more than minimal harm

15. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-03-28 · Health · corrected 2025-04-26

    Actual harm

16. DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2025-03-28 · Health · corrected 2025-04-26

    Potential for more than minimal harm

17. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-03-28 · Health · corrected 2025-04-26

    Potential for more than minimal harm

18. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-11-11 · Health · corrected 2024-11-23

    Potential for more than minimal harm

19. EF0700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.2024-11-11 · Health · corrected 2024-11-23

    Potential for more than minimal harm

20. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-10-21 · Health · corrected 2024-11-23

    Actual harm

21. 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.2024-10-21 · Health · corrected 2024-11-15

    Potential for more than minimal harm

22. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-09-12 · Health · corrected 2024-10-10

    Immediate jeopardy

23. DF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2024-09-12 · Health · corrected 2024-10-10

    Potential for more than minimal harm

24. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

25. DF0585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

26. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

27. DF0610Respond appropriately to all alleged violations.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

28. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

29. DF0687Provide appropriate foot care.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

30. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

31. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-06-27 · Health · corrected 2024-07-19

    Potential for more than minimal harm

32. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

33. DF0610Respond appropriately to all alleged violations.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

34. DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

35. DF0641Ensure each resident receives an accurate assessment.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

36. EF0645PASARR screening for Mental disorders or Intellectual Disabilities2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

37. EF0679Provide activities to meet all resident's needs.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

38. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

39. CF0732Post nurse staffing information every day.2024-05-02 · Health · corrected 2024-05-24

    Potential for minimal harm

40. DF0760Ensure that residents are free from significant medication errors.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

41. EF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

42. DF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

43. FF0880Provide and implement an infection prevention and control program.2024-05-02 · Health · corrected 2024-05-29

    Potential for more than minimal harm

44. EF0881Implement a program that monitors antibiotic use.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

45. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2024-05-02 · Health · corrected 2024-05-24

    Potential for more than minimal harm

46. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-04-10 · Health · corrected 2024-05-08

    Potential for more than minimal harm

47. DF0585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.2024-04-10 · Health · corrected 2024-05-08

    Potential for more than minimal harm

48. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-04-10 · Health · corrected 2024-05-08

    Potential for more than minimal harm

49. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-04-10 · Health · corrected 2024-05-08

    Potential for more than minimal harm

50. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-04-10 · Health · corrected 2024-05-08

    Potential for more than minimal harm

51. DF0759Ensure medication error rates are not 5 percent or greater.2024-04-10 · Health · corrected 2024-05-08

    Potential for more than minimal harm

52. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-01-08 · Health · corrected 2024-02-16

    Actual harm

53. DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-01-08 · Health · corrected 2024-01-17

    Potential for more than minimal harm

54. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-12-04 · Health · corrected 2023-12-22

    Potential for more than minimal harm

55. EF0610Respond appropriately to all alleged violations.2023-12-04 · Health · corrected 2023-12-22

    Potential for more than minimal harm

56. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-12-04 · Health · corrected 2024-02-16

    Immediate jeopardy

57. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-10-09 · Health · corrected 2023-10-23

    Potential for more than minimal harm

58. DF0610Respond appropriately to all alleged violations.2023-10-09 · Health · corrected 2023-11-02

    Potential for more than minimal harm

59. EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-10-09 · Health · corrected 2023-10-23

    Potential for more than minimal harm

60. DF0585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

61. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

62. EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

63. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-02-27 · Health · corrected 2023-03-27

    Actual harm

64. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

65. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

66. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

67. DF0759Ensure medication error rates are not 5 percent or greater.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

68. EF0811Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

69. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

70. FF0814Dispose of garbage and refuse properly.2023-02-27 · Health · corrected 2023-03-27

    Potential for more than minimal harm

Ownership

Other facilities in Madison

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.