nursing home in Madison, WI
Complete Care at Maple Grove LLC
3401 Maple Grove Dr., Madison, WI 53719 · (608) 845-1000
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★1
- Staffing★★★★★4
- Quality measures★★★★★4
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Complete Care at Maple Grove LLC at a glance
Complete Care at Maple Grove LLC is a 184-bed for-profit nursing home in Madison, Wisconsin (Dane County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the Wisconsin average of 3.
Residents receive about 5 hours of nursing care per day (1 of them from registered nurses), better than the state average of 4.2 hours.
Its most recent standard health inspection (May 5, 2025) found 25 health citations. The Wisconsin average is 9.5.
Federal regulators fined it 6 times in the past three years, totaling $153,657.
Nursing staff turnover is 64% per year (state average 46.9%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 184
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Complete Care
- Medicare-certified since
- January 1, 1977
- Resident/family council
- Both
- County
- Dane County
- CMS Certification Number
- 525276
Ratings
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 3 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 1 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 4 / 5 | 3.6 / 5 | 2.9 / 5 | Better |
| Quality measures rating ⓘ (higher is better) | 4 / 5 | 3 / 5 | 3.6 / 5 | Average |
| Long-stay quality rating (higher is better) | 4 / 5 | 3.1 / 5 | 3.8 / 5 | Average |
| Short-stay (rehab) quality rating (higher is better) | 3 / 5 | 3.1 / 5 | 3.3 / 5 | Average |
Staffing
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 4.97 hrs | 4.21 hrs | 3.86 hrs | Better |
| Registered nurse hours per resident per day (higher is better) | 1.04 hrs | 0.99 hrs | 0.69 hrs | Better |
| Nurse aide hours per resident per day (higher is better) | 3.23 hrs | 2.58 hrs | 2.32 hrs | Better |
| Weekend nurse staff hours per resident per day (higher is better) | 4.46 hrs | 3.77 hrs | 3.42 hrs | Better |
| Nursing staff turnover (yearly) (lower is better) | 64% | 46.9% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 60% | 39.7% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 25 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 12 | 4 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 217.5 | 100.3 | 80.6 | Worse |
Penalties
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 6 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $153,657 | $48,150 | $30,972 | Worse |
| All federal penalties in the past 3 years (lower is better) | 9 | 1 | 1 | Worse |
Size
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 184 | 77 | 107 | |
| Average residents per day | 110 | 55 | 86 | |
| Occupancy | 59.8% | 74% | 80.9% |
Long-stay residents
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 6.3% | 3.3% | 3.2% | Worse |
| Long-stay residents with pressure ulcers (lower is better) | 3.5% | 5% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 10.9% | 15.8% | 15.4% | Better |
| Long-stay residents with a urinary tract infection (lower is better) | 0.3% | 2.7% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 2.9% | 2.1% | 0.8% | Worse |
| Long-stay residents needing more help with daily activities (lower is better) | 6.3% | 16.1% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 9.2% | 18.4% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 5.4% | 5.1% | 5.2% | Average |
| Long-stay residents with depressive symptoms (lower is better) | 12.2% | 5.7% | 12.8% | Average |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 13% | 16.9% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 35.4% | 24.6% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 96.9% | 95% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 94.3% | 95.7% | 93.6% | Average |
Short-stay residents
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 1.3% | 1.2% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 84.8% | 82.2% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 78.9% | 86.5% | 82% | Average |
Inspection citations
State inspectors cited this home for 82 health deficiencies and 36 fire safety deficiencies in the inspection records CMS currently publishes. 7 citations involved actual harm, including 2 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 2, 2026 Complaint | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Tag F0690 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Tag F0849 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Tag F0699 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Honor 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Tag F0554 | D Potential harm, isolated | Corrected July 31, 2026 |
| July 2, 2026 Complaint | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Tag F0645 | D Potential harm, isolated | Corrected July 31, 2026 |
| June 25, 2026 Complaint | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected July 23, 2026 |
| July 29, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected August 12, 2025 |
| May 5, 2025 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Tag E0004 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Tag E0006 | F Potential harm, widespread | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | E Potential harm, pattern | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | E Potential harm, pattern | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0912 | E Potential harm, pattern | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Tag K0362 | E Potential harm, pattern | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Construct fire resistant interior walls. Smoke Deficiencies · Tag K0331 | E Potential harm, pattern | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | D Potential harm, isolated | Corrected June 24, 2025 |
| May 5, 2025 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | D Potential harm, isolated | Corrected June 24, 2025 |
| May 5, 2025 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected June 9, 2025 |
| May 5, 2025 Standard | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | E Potential harm, pattern | Corrected June 9, 2025 |
| May 5, 2025 Standard | Ensure 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected June 9, 2025 |
| May 5, 2025 Standard | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Honor each resident's preferences, choices, values and beliefs. Quality of Life and Care Deficiencies · Tag F0675 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Tag F0660 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Honor 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected June 9, 2025 |
| May 5, 2025 Standard | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Tag F0554 | D Potential harm, isolated | Corrected June 9, 2025 |
| March 28, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected April 26, 2025 |
| March 28, 2025 Complaint | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Tag F0805 | D Potential harm, isolated | Corrected April 26, 2025 |
| March 28, 2025 Complaint | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected April 26, 2025 |
| November 11, 2024 Complaint | Try 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. Quality of Life and Care Deficiencies · Tag F0700 | E Potential harm, pattern | Corrected November 23, 2024 |
| November 11, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected November 23, 2024 |
| October 21, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected November 23, 2024 |
| October 21, 2024 Complaint | Implement 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. Pharmacy Service Deficiencies · Tag F0758 | D Potential harm, isolated | Corrected November 15, 2024 |
| September 12, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected October 10, 2024 |
| September 12, 2024 Complaint | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Tag F0947 | D Potential harm, isolated | Corrected October 10, 2024 |
| June 27, 2024 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Honor 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Provide appropriate foot care. Quality of Life and Care Deficiencies · Tag F0687 | D Potential harm, isolated | Corrected July 19, 2024 |
| June 27, 2024 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected July 19, 2024 |
| May 2, 2024 Fire safety | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Tag E0006 | F Potential harm, widespread | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | F Potential harm, widespread | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0927 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Construct fire resistant interior walls. Smoke Deficiencies · Tag K0331 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | D Potential harm, isolated | Corrected June 14, 2024 |
| May 2, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | F Potential harm, widespread | Corrected May 29, 2024 |
| May 2, 2024 Complaint | Ensure 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Complaint | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Tag F0645 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Tag F0679 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Tag F0881 | E Potential harm, pattern | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Tag F0636 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Standard | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Tag F0804 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | D Potential harm, isolated | Corrected May 24, 2024 |
| May 2, 2024 Complaint | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Tag F0732 | C No harm, widespread | Corrected May 24, 2024 |
| April 10, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected May 8, 2024 |
| April 10, 2024 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected May 8, 2024 |
| April 10, 2024 Complaint | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected May 8, 2024 |
| April 10, 2024 Complaint | Honor 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected May 8, 2024 |
| April 10, 2024 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected May 8, 2024 |
| April 10, 2024 Complaint | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected May 8, 2024 |
| January 8, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected February 16, 2024 |
| January 8, 2024 Complaint | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Tag F0919 | D Potential harm, isolated | Corrected January 17, 2024 |
| December 4, 2023 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected February 16, 2024 |
| December 4, 2023 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | E Potential harm, pattern | Corrected December 22, 2023 |
| December 4, 2023 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected December 22, 2023 |
| October 9, 2023 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | E Potential harm, pattern | Corrected October 23, 2023 |
| October 9, 2023 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected November 2, 2023 |
| October 9, 2023 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected October 23, 2023 |
| February 27, 2023 Fire safety | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0914 | F Potential harm, widespread | Corrected April 27, 2023 |
| February 27, 2023 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | F Potential harm, widespread | Corrected April 27, 2023 |
| February 27, 2023 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | E Potential harm, pattern | Corrected July 6, 2023 |
| February 27, 2023 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | E Potential harm, pattern | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0927 | D Potential harm, isolated | Corrected April 27, 2023 |
| February 27, 2023 Fire safety | Construct fire resistant interior walls. Smoke Deficiencies · Tag K0331 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0912 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Tag K0362 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | G Actual harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected March 27, 2023 |
| February 27, 2023 Standard | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Tag F0814 | F Potential harm, widespread | Corrected March 27, 2023 |
| February 27, 2023 Standard | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected March 27, 2023 |
| February 27, 2023 Standard | Ensure 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. Nutrition and Dietary Deficiencies · Tag F0811 | E Potential harm, pattern | Corrected March 27, 2023 |
| February 27, 2023 Standard | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected March 27, 2023 |
| February 27, 2023 Standard | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Standard | Honor 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. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Standard | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Standard | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Tag F0690 | D Potential harm, isolated | Corrected March 27, 2023 |
| February 27, 2023 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected March 27, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 9 federal penalties in the past three years, including $153,657 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| May 5, 2025 | Payment Denial | 21 days from June 3, 2025 |
| May 5, 2025 | Fine | $58,354 |
| March 28, 2025 | Fine | $34,356 |
| October 21, 2024 | Payment Denial | 8 days from November 15, 2024 |
| October 21, 2024 | Fine | $12,048 |
| September 12, 2024 | Fine | $15,642 |
| December 4, 2023 | Payment Denial | 48 days from December 30, 2023 |
| December 4, 2023 | Fine | $18,018 |
| December 4, 2023 | Fine | $15,239 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| PC WCM OPCO HOLDCO LLC Organization | 5% or greater direct ownership interest | 100% | 02/28/2025 |
| PC WCM TOPCO LLC Organization | 5% or greater indirect ownership interest | — | 02/28/2025 |
| PEACE CAPITAL HOLDINGS II LLC Organization | 5% or greater indirect ownership interest | — | 02/28/2025 |
| SMS 2021 TRUST Organization | 5% or greater indirect ownership interest | — | 02/28/2025 |
| CHOLES, DIANA Individual | adp of the snf | NOT APPLICABLE | 02/02/2005 |
| DES CAPITAL LLC Organization | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| JRK INVESTMENTS LLC Organization | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| KLUGMAN, JACOB Individual | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| LEVERENTZ, LUANNE Individual | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| MAINA, JENNIFER Individual | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| MURPHY, SEAN Individual | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| PC WCM PROPCO HOLDCO LLC Organization | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| PC WCM TOPCO LLC Organization | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| PEACE CAPITAL HOLDINGS II LLC Organization | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| SMS 2021 TRUST Organization | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| STEIN, SHALOM Individual | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| STERNBUCH, DANIEL Individual | adp of the snf | NOT APPLICABLE | 02/28/2025 |
| STEIN, SHALOM Individual | corporate officer | NOT APPLICABLE | 02/28/2025 |
| KLUGMAN, JACOB Individual | indirect ownership interest | NOT APPLICABLE | 02/28/2025 |
| STEIN, SHALOM Individual | indirect ownership interest | NOT APPLICABLE | 02/28/2025 |
| HELLMAN, YOSEF Individual | managing control - governing body | NOT APPLICABLE | 02/28/2025 |
| STEIN, SHALOM Individual | managing control - governing body | NOT APPLICABLE | 02/28/2025 |
| CHOLES, DIANA Individual | operational/managerial control | NOT APPLICABLE | 02/28/2025 |
| HELLMAN, YOSEF Individual | operational/managerial control | NOT APPLICABLE | 02/28/2025 |
| MAINA, JENNIFER Individual | operational/managerial control | NOT APPLICABLE | 02/28/2025 |
| MURPHY, SEAN Individual | operational/managerial control | NOT APPLICABLE | 02/28/2025 |
| STERNBUCH, DANIEL Individual | operational/managerial control | NOT APPLICABLE | 02/28/2025 |
| STEIN, SHALOM Individual | trustee of the snf | NOT APPLICABLE | 02/28/2025 |
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Frequently asked questions
What is Complete Care at Maple Grove LLC's rating?
Complete Care at Maple Grove LLC has 1 out of 5 stars on the CMS overall star rating. The average for Wisconsin nursing homes is 3 stars.
How many inspection citations did Complete Care at Maple Grove LLC receive?
Its most recent standard health inspection found 25 citations, compared with a Wisconsin average of 9.5. Every citation is listed on this page with its severity.
Does Complete Care at Maple Grove LLC accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Complete Care at Maple Grove LLC?
It is for profit - corporation and part of Complete Care. The ownership section on this page lists the owners and managers reported to CMS.
Where is Complete Care at Maple Grove LLC and how do I contact it?
Complete Care at Maple Grove LLC is at 3401 Maple Grove Dr., Madison, WI 53719. Phone: (608) 845-1000.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.