Cycle 1
Health 2024-11-06 · Fire 2024-11-06
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Madison, WI
Capitol Lakes Health Center
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
333 W Main St, Madison, WI
(608) 283-2000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Pacific Retirement Services
Operator or chain grouping
Approved since
1979-09-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.02
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
4.98
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
7.79
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.80
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
6.18
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.99
CMS adjusted RN staffing hours
Adjusted total hours
7.67
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
280
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0243
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 16.81% · Performance 16.95% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
6.50
Baseline 4.26% · Performance 5.89% · Measure score 6.50 · Achievement 6.50 · Improvement 0
Total nurse turnover
3.35
Baseline 45.35% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.31 hours · Performance 5.89 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.76% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 242 · Observed rate 4.96% · Lower 95% interval 5.93% |
| Discharge to community | 72.53% |
50.57%
22 pts better
|
Better than the National Rate · Eligible stays 237 · Observed rate 75.53% · Lower 95% interval 67.86% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 139 · Denominator 139 |
| Falls with major injury | 0.72% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 139 |
| Discharge self-care score | 53.91% |
53.69%
0.2 pts better
|
Numerator 62 · Denominator 115 |
| Discharge mobility score | 39.13% |
50.94%
11.8 pts worse
|
Numerator 45 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 4.32% |
2.29%
2 pts worse
|
Numerator 6 · Denominator 139 · Adjusted rate 6.37% |
| Healthcare-associated infections requiring hospitalization | 5.89% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 2.61% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 27.22% |
8.2%
19 pts better
|
Numerator 43 · Denominator 158 |
| Staff flu vaccination coverage | 48.31% |
42%
6.3 pts better
|
Numerator 100 · Denominator 207 |
| Discharge function score | 46.96% |
56.45%
9.5 pts worse
|
Numerator 54 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 78.31% |
25.2%
53.1 pts better
|
Numerator 65 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
5.0%
3.2 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
4.9%
2.6 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
16.6%
1 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
16.7%
4.9 pts worse
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
17.3%
7.5 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
25.5%
0.6 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
5.5%
5.5 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
86.8%
13 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.2% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
15.0%
3 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 10.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
82.2%
16.3 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.7%
0.1 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 17.9% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
K223 · Egress Deficiencies
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.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-06
F · Potential for more than minimal harm
2023-10-05
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-10-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-10-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-10-05
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-10-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-10-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-23
F · Potential for more than minimal harm
2022-08-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-08-11
K223 · Egress Deficiencies
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.
Corrected 2022-08-30
E · Potential for more than minimal harm
2022-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-11
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-08-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-08-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-08-11
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-08-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-06
F · Potential for more than minimal harm
2023-10-05
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-03
G · Actual harm
2023-06-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-18
D · Potential for more than minimal harm
2022-08-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-08
B · Minimal harm
2022-08-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-09
Penalties and ownership
What sits behind the stars
Ownership
Bishop, Richard
Corporate Officer · Individual
Center, Sue
Corporate Officer · Individual
Conroy, Timothy
W-2 Managing Employee · Individual
Drew, Sally
Corporate Director · Individual
Johannsen, Stephen
Corporate Officer · Individual
Kbc Bank Nv
5% Or Greater Security Interest · Organization
Lapis Municipal Opportunities Fund Iii LP
5% Or Greater Security Interest · Organization
Norrbom, Clay
Corporate Officer · Individual
Pacific Retirement Services Inc
Operational/Managerial Control · Organization
Peterson, Harry
Corporate Officer · Individual
Sholty, Eric
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Oak Park Place of Nakoma
Madison, WI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Madison Health And Rehabilitation Center
Madison, WI
0-star overall rating with 0-star inspections with Special Focus status with $413,433 in total fines with 10 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Middleton Village Nursing And Rehab
Middleton, WI
1-star overall rating with 1-star inspections with $84,573 in total fines with 18 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Jump out