01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-10 | 1 | 2026-03-10 | 10 |
| Cycle 2 | 2024-11-06 | 8 | 2024-11-06 | 9 |
| Cycle 3 | 2023-10-05 | 4 | 2023-10-05 | 9 |
CMS CCN 5253052026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Capitol Lakes Health Center
333 W Main St · Madison, WI 53703 · Dane County
Certified beds49CMS provider file
Recent citation rows41current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
41 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-10 · HEALTHF0678Severity J · isolated immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0223Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0912Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have power receptacles that are properly grounded.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-10 · FIREK0919Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Correction field: Deficient, Provider has date of correction · 2026-03-312024-11-06 · HEALTHF0684Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-12-06 · complaint2024-11-06 · HEALTHF0687Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · HEALTHF0688Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · HEALTHF0804Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · HEALTHF0812Severity F · widespread; 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.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · FIREK0293Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-11-06 · FIREK0541Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Correction field: Deficient, Provider has date of correction · 2024-12-0603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- KBC BANK NVOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 01/01/2022
- LAPIS MUNICIPAL OPPORTUNITIES FUND III LPOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 01/01/2022
- CONROY, TIMOTHYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/23/2009
- DREW, SALLYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/10/2016
- BISHOP, RICHARDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2021
- CENTER, SUEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/21/2017
- JOHANNSEN, STEPHENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/16/2019
- NORRBOM, CLAYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/17/2017
- PETERSON, HARRYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/21/2017
- SHOLTY, ERICIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/27/2018
- PACIFIC RETIREMENT SERVICES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2008
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours6.69per resident day
RN hours2.00per resident day
Weekend nurse hours5.59per resident day
Staff turnover57.3%CMS reported field
06 / LOCAL RECORDS
Open the Madison ledger →Other published facilities nearby
Complete Care At Maple Grove Llc184 beds · CMS overall 1/5118 citation rowsHebron Oaks70 beds · CMS overall 4/537 citation rowsMadison Health And Rehabilitation Center83 beds · CMS overall 1/584 citation rowsOak Park Nursing And Rehab Center100 beds · CMS overall 1/576 citation rowsOakwood Village East Health And Rehab Center40 beds · CMS overall 3/539 citation rowsOak Park Place Of Nakoma33 beds · CMS overall 3/557 citation rows