Federal inspection record · CMS data as of October 1, 2026
Complete Care at Maple Grove LLC
3401 Maple Grove Dr., Madison, WI · (608) 845-1000
- Certified beds
- 184
- Residents per day
- 104
- Ownership
- For-Profit
- Chain
- Complete Care
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 1, 1977
1
How this home got 1 star
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.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
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.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Complete Care at Maple Grove LLC carries 172.5 inspection points. That is fewer than 15% 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
71 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 (6)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care20E
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 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
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Honor each resident's preferences, choices, values and beliefs.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- E
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate foot care.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide activities to meet all resident's needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights9E
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
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.
Freedom from Abuse, Neglect, and Exploitation9E
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- E
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning8E
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Plan the resident's discharge to meet the resident's goals and needs.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Pharmacy Service8E
- D
Ensure that residents are free from significant medication errors.
- E
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.
- 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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
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.
- D
Ensure that residents are free from significant medication errors.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
Nutrition and Dietary4F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Infection Control3F
- F
Provide and implement an infection prevention and control program.
- E
Implement a program that monitors antibiotic use.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Nursing and Physician Services2D
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- C
Post nurse staffing information every day.
Administration1D
- D
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.
Environmental1D
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspection history
2026-07-02
12 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2025-05-05
21 health deficiencies · 14 fire-safety deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
2024-05-02
38 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 45 min of nursing staff time a day, 1 h 2 min of it from a registered nurse.
This home
4 h 45 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 55% of nursing staff and 35% 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
Fines and payment denials
$153,657 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-05-05 | Fine | $58,354 |
| 2025-05-05 | Payment Denial · 21 day denial | $0 |
| 2025-03-28 | Fine | $34,356 |
| 2024-10-21 | Fine | $12,048 |
| 2024-10-21 | Payment Denial · 8 day denial | $0 |
| 2024-09-12 | Fine | $15,642 |
| 2023-12-04 | Fine | $15,239 |
| 2023-12-04 | Fine | $18,018 |
| 2023-12-04 | Payment Denial · 48 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.5 pts worse | 2.1 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1 pts better | 1.2 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.9 pts better | 96.9% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.7 pts worse | 89.9% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.9 pts worse | 6.2% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms13.5 pts worse | 19.5% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.1 pts better | 3.8% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication2.2 pts better | 14.6% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication4.4 pts better | 11.5% | 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 ability to walk independently worsened10.1 pts better | 6.9% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased9.8 pts better | 6.0% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.8 pts worse | 2.7% | 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 incontinence7.6 pts worse | 31.2% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.9 pts better | 4.0% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine0.4 pts worse | 86.5% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.2 pts better | 15.4% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.4 pts better | 0.8% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine8.9 pts worse | 73.3% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission5.7 pts worse | 28.2% | 22.5% | 23.4% |
·
Who owns and runs it
28 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 |
|---|---|---|---|
| Pc Wcm Opco Holdco LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 3 facilities |
| Choles, Diana | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Choles, Diana | Adp Of The SNF · Individual | 0% | 1 facilities |
| Des Capital LLC | Adp Of The SNF · Organization | 0% | 28 facilities |
| Hellman, Yosef | Managing Control - Governing Body · Individual | 0% | 19 facilities |
| Hellman, Yosef | Operational/Managerial Control · Individual | 0% | 19 facilities |
| Jrk Investments LLC | Adp Of The SNF · Organization | 0% | 28 facilities |
| Klugman, Jacob | Indirect Ownership Interest · Individual | 0% | 30 facilities |
| Klugman, Jacob | Adp Of The SNF · Individual | 0% | 30 facilities |
| Leverentz, Luanne | Adp Of The SNF · Individual | 0% | 3 facilities |
| Maina, Jennifer | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Maina, Jennifer | Adp Of The SNF · Individual | 0% | 1 facilities |
| Murphy, Sean | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Murphy, Sean | Adp Of The SNF · Individual | 0% | 2 facilities |
| Pc Wcm Propco Holdco LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Pc Wcm Topco LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 3 facilities |
| Pc Wcm Topco LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Peace Capital Holdings Ii LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 20 facilities |
| Peace Capital Holdings Ii LLC | Adp Of The SNF · Organization | 0% | 20 facilities |
| Sms 2021 Trust | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 77 facilities |
| Sms 2021 Trust | Adp Of The SNF · Organization | 0% | 77 facilities |
| Stein, Shalom | Indirect Ownership Interest · Individual | 0% | 87 facilities |
| Stein, Shalom | Managing Control - Governing Body · Individual | 0% | 87 facilities |
| Stein, Shalom | Corporate Officer · Individual | 0% | 87 facilities |
| Stein, Shalom | Trustee Of The SNF · Individual | 0% | 87 facilities |
| Stein, Shalom | Adp Of The SNF · Individual | 0% | 87 facilities |
| Sternbuch, Daniel | Operational/Managerial Control · Individual | 0% | 31 facilities |
| Sternbuch, Daniel | Adp Of The SNF · Individual | 0% | 31 facilities |
·
Fire safety
32 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke16F
- F
Provide properly protected cooking facilities.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Construct fire resistant interior walls.
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E
Install corridor and hallway doors that block smoke.
- D
Install an approved automatic sprinkler system.
- F
Provide properly protected cooking facilities.
- E
Construct fire resistant interior walls.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Install an approved automatic sprinkler system.
Gas, Vacuum, and Electrical Systems9F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the installation and maintenance of electrical systems.
- D
Ensure proper usage of power strips and extension cords.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have power receptacles that are properly grounded.
- E
Meet requirements for the use of electrical equipment.
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- D
Have generator or other power source capable of supplying service within 10 seconds.
Emergency Preparedness4F
- F
Conduct testing and exercise requirements.
- F
Develop and maintain an Emergency Preparedness Program (EP).
- F
Conduct risk assessment and an All-Hazards approach.
- F
Conduct risk assessment and an All-Hazards approach.
Services2F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous1F
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
·
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-
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-
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