64/100
Average
333 W Main St, Madison, WI 53703
These are findings in the public CMS record for this home. They are not our opinion — each one comes straight from a federal inspection or enforcement file.
1 citation(s) involving actual harm or immediate jeopardy
Inspectors found violations at scope/severity G or above, meaning residents were harmed or placed in immediate jeopardy.
Every point is shown. Nothing is weighted behind the scenes — the full formula is on How we grade.
Citations from state health inspections over the last three surveys, weighted by how much harm CMS says they caused.
Nursing hours per resident per day, adjusted for how sick the residents are, plus RN cover and weekend consistency.
How much of the nursing team leaves in a year. High turnover means a resident rarely sees the same face twice.
The CMS quality-measure rating, built from resident outcomes like falls, pressure ulcers, infections and antipsychotic use.
Fines and payment denials CMS has imposed. A denial of payment means CMS stopped paying for new admissions.
Grade ceiling applied
Hours of nursing care each resident receives per day. The marker on each bar is the national average.
RNs are the licence level most likely to catch a resident deteriorating.
The shift most families visit, and the one thinned first.
The share of nursing staff who left over the last year.
Last standard health inspection: March 10, 2026 (5 months ago).
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Immediate jeopardy to resident health or safety
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate foot care.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
No actual harm, potential for more than minimal harm
Part of PACIFIC RETIREMENT SERVICES, which operates 10 homes. Staffing budgets are usually set at chain level, not in the building.
| Owner | Type | Role | Since |
|---|---|---|---|
| KBC BANK NV | Organization | 5% OR GREATER SECURITY INTEREST | — |
| LAPIS MUNICIPAL OPPORTUNITIES FUND III LP | Organization | 5% OR GREATER SECURITY INTEREST | — |
| CONROY, TIMOTHY | Individual | W-2 MANAGING EMPLOYEE | — |
| DREW, SALLY | Individual | CORPORATE DIRECTOR | — |
| BISHOP, RICHARD | Individual | CORPORATE OFFICER | — |
| CENTER, SUE | Individual | CORPORATE OFFICER | — |
| JOHANNSEN, STEPHEN | Individual | CORPORATE OFFICER | — |
| NORRBOM, CLAY | Individual | CORPORATE OFFICER | — |
| PETERSON, HARRY | Individual | CORPORATE OFFICER | — |
| SHOLTY, ERIC | Individual | CORPORATE OFFICER | — |
| PACIFIC RETIREMENT SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — |
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Capitol Lakes Health Center holds an ElderGrade of C (64 out of 100), which we describe as "average". The grade combines its inspection citations, nurse staffing levels, staff turnover, resident outcomes and enforcement history from the federal CMS record.
Residents receive an average of 6.69 nursing hours per day across all nursing staff, against a national average of 3.86 hours.
Yes. 1 of the 13 citations on record were scored at scope and severity G or above, meaning inspectors found actual harm to a resident or immediate jeopardy to resident safety.
Yes, Capitol Lakes Health Center is certified to accept Medicaid, which is the programme that pays for long-term custodial care once a resident meets their state's income and asset limits.