nursing home in Madison, WI
Capitol Lakes Health Center
333 W Main St, Madison, WI 53703 · (608) 283-2000
★★★★★4
Above average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★3
- Staffing★★★★★5
- Quality measures★★★★★3
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Capitol Lakes Health Center at a glance
Capitol Lakes Health Center is a 49-bed non-profit nursing home in Madison, Wisconsin (Dane County).
CMS gives it 4 out of 5 stars on its overall star rating, better than the Wisconsin average of 3.
Residents receive about 6.7 hours of nursing care per day (2 of them from registered nurses), better than the state average of 4.2 hours.
Its most recent standard health inspection (March 10, 2026) found 1 health citation. The Wisconsin average is 9.5.
It has not received a federal fine in the past three years.
Nursing staff turnover is 57.3% per year (state average 46.9%).
Facility details
- Type
- Nursing home
- Ownership
- Non Profit - Corporation
- Beds
- 49
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Pacific Retirement Services
- Medicare-certified since
- September 4, 1979
- Resident/family council
- Resident
- County
- Dane County
- CMS Certification Number
- 525305
Ratings
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 4 / 5 | 3 / 5 | 3 / 5 | Better |
| Health inspection rating ⓘ (higher is better) | 3 / 5 | 2.8 / 5 | 2.8 / 5 | Average |
| Staffing rating ⓘ (higher is better) | 5 / 5 | 3.6 / 5 | 2.9 / 5 | Better |
| Quality measures rating ⓘ (higher is better) | 3 / 5 | 3 / 5 | 3.6 / 5 | Worse |
| 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) | 6.69 hrs | 4.21 hrs | 3.86 hrs | Better |
| Registered nurse hours per resident per day (higher is better) | 2.00 hrs | 0.99 hrs | 0.69 hrs | Better |
| Nurse aide hours per resident per day (higher is better) | 3.91 hrs | 2.58 hrs | 2.32 hrs | Better |
| Weekend nurse staff hours per resident per day (higher is better) | 5.59 hrs | 3.77 hrs | 3.42 hrs | Better |
| Nursing staff turnover (yearly) (lower is better) | 57.3% | 46.9% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 25% | 39.7% | 42.9% | Better |
| 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) | 1 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 0 | 4 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 74.3 | 100.3 | 80.6 | Better |
Penalties
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
| Total fines in the past 3 years (lower is better) | $0 | $48,150 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
Size
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 49 | 77 | 107 | |
| Average residents per day | 26 | 55 | 86 | |
| Occupancy | 53.3% | 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) | 3.3% | 3.3% | 3.2% | Average |
| Long-stay residents with pressure ulcers (lower is better) | 6.2% | 5% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 25.6% | 15.8% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 0% | 2.7% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 2.1% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 15.4% | 16.1% | 13.9% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 2.4% | 5.1% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 1.7% | 5.7% | 12.8% | Better |
| 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) | 18.6% | 16.9% | 19.5% | Average |
| Long-stay residents with new or worse incontinence (lower is better) | 32.7% | 24.6% | 19% | Worse |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 95.7% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 1.1% | 1.2% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 98.5% | 82.2% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 99.6% | 86.5% | 82% | Better |
Inspection citations
State inspectors cited this home for 13 health deficiencies and 28 fire safety deficiencies in the inspection records CMS currently publishes. 1 citation involved actual harm, including 1 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| March 10, 2026 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | E Potential harm, pattern | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0912 | E Potential harm, pattern | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | E Potential harm, pattern | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | E Potential harm, pattern | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Have properly located and lighted "Exit" signs. Egress Deficiencies · Tag K0293 | E Potential harm, pattern | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | D Potential harm, isolated | Corrected March 31, 2026 |
| March 10, 2026 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | D Potential harm, isolated | Corrected March 31, 2026 |
| March 10, 2026 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 31, 2026 |
| March 10, 2026 Fire safety | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Tag K0223 | D Potential harm, isolated | Corrected March 31, 2026 |
| March 10, 2026 Standard | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Tag F0678 | J Immediate jeopardy, isolated | Corrected March 31, 2026 |
| November 6, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | E Potential harm, pattern | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Tag K0541 | E Potential harm, pattern | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Tag K0223 | E Potential harm, pattern | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923 | D Potential harm, isolated | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0911 | D Potential harm, isolated | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | D Potential harm, isolated | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | D Potential harm, isolated | Corrected December 6, 2024 |
| November 6, 2024 Fire safety | Have properly located and lighted "Exit" signs. Egress Deficiencies · Tag K0293 | D Potential harm, isolated | Corrected December 6, 2024 |
| November 6, 2024 Standard | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Tag F0804 | F Potential harm, widespread | Corrected December 6, 2024 |
| November 6, 2024 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 December 6, 2024 |
| November 6, 2024 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | F Potential harm, widespread | Corrected December 6, 2024 |
| November 6, 2024 Standard | Provide appropriate foot care. Quality of Life and Care Deficiencies · Tag F0687 | E Potential harm, pattern | Corrected December 6, 2024 |
| November 6, 2024 Standard | Provide 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. Quality of Life and Care Deficiencies · Tag F0688 | D Potential harm, isolated | Corrected December 6, 2024 |
| November 6, 2024 Standard | 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 December 6, 2024 |
| November 6, 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 December 6, 2024 |
| November 6, 2024 Standard | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0698 | D Potential harm, isolated | Corrected December 6, 2024 |
| October 5, 2023 Fire safety | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Tag K0131 | F Potential harm, widespread | Corrected December 19, 2023 |
| October 5, 2023 Fire safety | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Tag K0354 | F Potential harm, widespread | Corrected October 23, 2023 |
| October 5, 2023 Fire safety | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0911 | E Potential harm, pattern | Corrected October 26, 2023 |
| October 5, 2023 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | E Potential harm, pattern | Corrected October 23, 2023 |
| October 5, 2023 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | E Potential harm, pattern | Corrected October 18, 2023 |
| October 5, 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 October 18, 2023 |
| October 5, 2023 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | D Potential harm, isolated | Corrected October 16, 2023 |
| October 5, 2023 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 October 23, 2023 |
| October 5, 2023 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | D Potential harm, isolated | Corrected October 23, 2023 |
| October 5, 2023 Standard | Ensure 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. Nutrition and Dietary Deficiencies · Tag F0809 | F Potential harm, widespread | Corrected November 3, 2023 |
| October 5, 2023 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected November 3, 2023 |
| October 5, 2023 Standard | 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 3, 2023 |
| October 5, 2023 Standard | Honor 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. Resident Rights Deficiencies · Tag F0578 | D Potential harm, isolated | Corrected November 3, 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 no federal fines or payment denials in the past three years.
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| KBC BANK NV Organization | 5% or greater security interest | NOT APPLICABLE | 01/01/2022 |
| LAPIS MUNICIPAL OPPORTUNITIES FUND III LP Organization | 5% or greater security interest | NOT APPLICABLE | 01/01/2022 |
| DREW, SALLY Individual | corporate director | NOT APPLICABLE | 10/10/2016 |
| BISHOP, RICHARD Individual | corporate officer | NOT APPLICABLE | 10/01/2021 |
| CENTER, SUE Individual | corporate officer | NOT APPLICABLE | 06/21/2017 |
| JOHANNSEN, STEPHEN Individual | corporate officer | NOT APPLICABLE | 01/16/2019 |
| NORRBOM, CLAY Individual | corporate officer | NOT APPLICABLE | 11/17/2017 |
| PETERSON, HARRY Individual | corporate officer | NOT APPLICABLE | 06/21/2017 |
| SHOLTY, ERIC Individual | corporate officer | NOT APPLICABLE | 05/27/2018 |
| PACIFIC RETIREMENT SERVICES INC Organization | operational/managerial control | NOT APPLICABLE | 04/01/2008 |
| CONROY, TIMOTHY Individual | w-2 managing employee | NOT APPLICABLE | 03/23/2009 |
Other nursing homes near Capitol Lakes Health Center
- ★★★★★3Average
Madison Health and Rehabilitation Center
110 Belmont Rd., Madison, WI 53714 · 4.1 mi
For-profit · 83 beds · Part of Champion Care
★★★★★1Much below averageMiddleton Village Nursing and Rehab
6201 Elmwood Ave, Middleton, WI 53562 · 5.4 mi
For-profit · 97 beds · Part of Shlomo Hoffman
★★★★★1Much below average- ★★★★★1Much below average
- ★★★★★4Above average
Complete Care at Maple Grove LLC
3401 Maple Grove Dr., Madison, WI 53719 · 7 mi
For-profit · 184 beds · Part of Complete Care
★★★★★1Much below average
Frequently asked questions
What is Capitol Lakes Health Center's rating?
Capitol Lakes Health Center has 4 out of 5 stars on the CMS overall star rating. The average for Wisconsin nursing homes is 3 stars.
How many inspection citations did Capitol Lakes Health Center receive?
Its most recent standard health inspection found 1 citation, compared with a Wisconsin average of 9.5. Every citation is listed on this page with its severity.
Does Capitol Lakes Health Center 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 Capitol Lakes Health Center?
It is non profit - corporation and part of Pacific Retirement Services. The ownership section on this page lists the owners and managers reported to CMS.
Where is Capitol Lakes Health Center and how do I contact it?
Capitol Lakes Health Center is at 333 W Main St, Madison, WI 53703. Phone: (608) 283-2000.
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.