Federal inspection record · CMS data as of October 1, 2026
Capitol Lakes Health Center
333 W Main St, Madison, WI · (608) 283-2000
- Certified beds
- 49
- Residents per day
- 29
- Ownership
- Non-Profit
- Chain
- Pacific Retirement Services
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 4, 1979
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
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Staffing
★★★★★+1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Capitol Lakes Health Center carries 74.25 inspection points. That is fewer than 44% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
13 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Everything else, by area of care
Quality of Life and Care5E
- E
Provide appropriate foot care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
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.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Nutrition and Dietary3F
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
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.
Pharmacy Service2D
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
Infection Control1F
- F
Provide and implement an infection prevention and control program.
Resident Rights1D
- D
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.
Inspection history
2026-03-10
1 health deficiencies · 10 fire-safety deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2024-11-06
8 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2023-10-05
4 health deficiencies · 9 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 6 h 13 min of nursing staff time a day, 1 h 51 min of it from a registered nurse.
This home
6 h 13 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 58% of nursing staff and 29% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine4 pts better | 100.0% | 96.0% | 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury5.3 pts worse | 8.6% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.2 pts better | 1.8% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.2 pts worse | 5.1% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication3.2 pts worse | 20.0% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication10.4 pts worse | 26.3% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.9 pts worse | 16.7% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.7 pts better | 1.2% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.7 pts better | 0.0% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.6 pts worse | 33.2% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.1 pts better | 3.8% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.6 pts better | 99.5% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.6 pts better | 12.0% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.6 pts better | 0.6% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine16 pts better | 98.2% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.3 pts better | 20.2% | 22.5% | 23.4% |
·
Who owns and runs it
11 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bishop, Richard | Corporate Officer · Individual | 0% | 1 facilities |
| Center, Sue | Corporate Officer · Individual | 0% | 1 facilities |
| Conroy, Timothy | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Drew, Sally | Corporate Director · Individual | 0% | 1 facilities |
| Johannsen, Stephen | Corporate Officer · Individual | 0% | 1 facilities |
| Kbc Bank Nv | 5% Or Greater Security Interest · Organization | 0% | 1 facilities |
| Lapis Municipal Opportunities Fund Iii LP | 5% Or Greater Security Interest · Organization | 0% | 1 facilities |
| Norrbom, Clay | Corporate Officer · Individual | 0% | 1 facilities |
| Pacific Retirement Services Inc | Operational/Managerial Control · Organization | 0% | 9 facilities |
| Peterson, Harry | Corporate Officer · Individual | 0% | 1 facilities |
| Sholty, Eric | Corporate Officer · Individual | 0% | 2 facilities |
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Fire safety
28 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Provide properly protected cooking facilities.
- E
Install an approved automatic sprinkler system.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Inspect, test, and maintain automatic sprinkler systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- E
Install corridor and hallway doors that block smoke.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Gas, Vacuum, and Electrical Systems7E
- E
Have power receptacles that are properly grounded.
- D
Meet requirements for the use of electrical equipment.
- D
Meet requirements for the installation and maintenance of electrical systems.
- D
Meet requirements for the use of electrical equipment.
- D
Ensure proper usage of power strips and extension cords.
- D
Have proper medical gas storage and administration areas.
- E
Meet requirements for the installation and maintenance of electrical systems.
Egress5E
- E
Have properly located and lighted "Exit" signs.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D
Have properly located and lighted "Exit" signs.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Services2E
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Install properly constructed and protected linen or trash chutes.
Construction1F
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
Miscellaneous1D
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
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Other homes nearby
-
Oak Park Place of Nakoma
Madison, WI
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 5 h 56 min
- Fines
- $0
-
Madison Health and Rehabilitation Center
Madison, WI · Champion Care
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 43 min
- Fines
- $289,198
-
Middleton Village Nursing And Rehab
Middleton, WI · Shlomo Hoffman
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 57 min
- Fines
- $67,772