Nursing homes › Wisconsin › Capitol Lakes Health Center
333 W Main St, Madison, WI 53703 · 6082832000 · 49 certified beds
Per CMS filings, this facility is affiliated with Pacific Retirement Services, a group operating 10 facilities in 5 states. Group record: average rating 4.6/5, 0 abuse citation icons, 0 facilities on the Special Focus list, $10,033 in federal fines. This facility rates below its group average (4.6/5).
Total nurse staffing: 6.69 (Wisconsin median: 4.06). RN hours: 2.00. Weekend total: 5.59. Nursing staff turnover: 57%.
All-time on record: 13 deficiency citations, including 1 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-03-10 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J | Health | corrected 2026-03-31 |
| 2024-11-06 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F | Health | corrected 2024-12-06 |
| 2024-11-06 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2024-12-06 |
| 2024-11-06 | Provide and implement an infection prevention and control program. | F | Health | corrected 2024-12-06 |
| 2024-11-06 | Provide appropriate foot care. | E | Health | corrected 2024-12-06 |
| 2024-11-06 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2024-12-06 |
| 2024-11-06 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | complaint | corrected 2024-12-06 |
| 2024-11-06 | 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 | Health | corrected 2024-12-06 |
| 2024-11-06 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Health | corrected 2024-12-06 |
| 2023-10-05 | 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. | F | Health | corrected 2023-11-03 |
| 2023-10-05 | 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. | D | Health | corrected 2023-11-03 |
| 2023-10-05 | 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 | Health | corrected 2023-11-03 |
| 2023-10-05 | Ensure medication error rates are not 5 percent or greater. | D | Health | corrected 2023-11-03 |
No federal fines or payment denials on record.
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| DREW, SALLY | Corporate Director | Individual | NOT APPLICABLE | since 10/10/2016 |
| BISHOP, RICHARD | Corporate Officer | Individual | NOT APPLICABLE | since 10/01/2021 |
| CENTER, SUE | Corporate Officer | Individual | NOT APPLICABLE | since 06/21/2017 |
| JOHANNSEN, STEPHEN | Corporate Officer | Individual | NOT APPLICABLE | since 01/16/2019 |
| NORRBOM, CLAY | Corporate Officer | Individual | NOT APPLICABLE | since 11/17/2017 |
| PETERSON, HARRY | Corporate Officer | Individual | NOT APPLICABLE | since 06/21/2017 |
| SHOLTY, ERIC | Corporate Officer | Individual | NOT APPLICABLE | since 05/27/2018 |
| PACIFIC RETIREMENT SERVICES INC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2008 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 525305. Corrections: data@carerecords.org.