Nursing homeActive
Capitol Lakes Health Center
333 W Main St, Madison, WI 53703608283200049 certified beds · 26 residentsNon profit - CorporationMedicare and Medicaid
Surveys on file
3
since 2023
Deficiencies
13
● 0● 12● 1
Penalties · 3 yrs
—
none on file
Last survey
2026-03-10
Standard
CMS overall
4 / 5
stars as published by CMS
CMS overall 4/5
Health 3
Staffing 5
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Wisconsin Division of Quality Assurance · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-10 | Standard | 001 | CMS-2567 (Care Compare) | — |
| 2024-11-06 | Standard | 080 | CMS-2567 (Care Compare) | — |
| 2023-10-05 | Standard | 040 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Wisconsin Division of Quality Assurance publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-03-31Record 525305-20260310-F678
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F686
F687Provide appropriate foot care.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F687
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F688
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F698
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F812
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-06Record 525305-20241106-F880
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 525305-20231005-F578
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 525305-20231005-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 525305-20231005-F759
F809Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 525305-20231005-F809
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day2.00
Facility
Wisconsin
National
Wisconsin 0.99 · National 0.69
Total nurse hours per resident day6.69
Facility
Wisconsin
National
Wisconsin 4.21 · National 3.86
Weekend total nurse hours5.59
Facility
Wisconsin
National
Wisconsin 3.77 · National 3.42
Total nursing staff turnover57%
Facility
Wisconsin
National
Wisconsin 47% · National 46%
Registered nurse turnover25%
Facility
Wisconsin
National
Wisconsin 40% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Wisconsin | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 6.2% | 5.0% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 3.3% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 25.6% | 15.8% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 2.7% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 15.4% | 16.1% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.4% | 5.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 18.6% | 16.9% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Pacific Retirement Services Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Bishop, Richard Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Center, Sue Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Conroy, Timothy Individual | W-2 MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Drew, Sally Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Johannsen, Stephen Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Kbc Bank Nv Organization | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE | — | — |
| Lapis Municipal Opportunities Fund III LP Organization | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE | — | — |
| Norrbom, Clay Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Peterson, Harry Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Sholty, Eric Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
Part of a chain
Pacific Retirement Services — 10 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wisconsin.
No county cost figures on file for Dane.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Oak Park Place of Nakoma Madison | 3.8 mi | 2026-01-22 | 1220 |
| Madison Health and Rehabilitation Center Madison | 4.1 mi | 2026-04-08 | 0469 |
| Middleton Village Nursing And Rehab Middleton | 5.4 mi | 2026-03-05 | 0594 |
| Oak Park Nursing And Rehab Center Madison | 5.4 mi | 2026-05-14 | 0334 |
| Hebron Oaks Madison | 6.2 mi | 2026-01-08 | 061 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |