Capitol Lakes Health Center — nursing home in Madison, WI

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 49 CMS-certified beds (not state-licensed beds)
Licensed beds: State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead.
Average residents per day: 29.4 CMS, MDS-derived
CMS Certification Number: 525305
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): Sep 4, 1979
Ownership type: Non profit - Corporation
Operator (legal business name): Capitol Lakes Inc
CMS chain: Pacific Retirement Services 10 facilities
Phone: (608) 283-2000
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

6

latest Mar 10, 2026

Citations

41

13 health · 28 fire

Harm or worse

1

1 immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J1	K·	L·
Actual harm	G·	H·	I·
Potential harm	D20	E12	F8
Minimal	A·	B·	C·

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

0

$0

Payment denials

0

Latest

—

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 525305
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 49
First approved: Sep 4, 1979
Located in a hospital: No
Status: Active CMS certification as of CMS release Oct 1, 2026
Evidence: Verified

State license

State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead. State coverage for Wisconsin.

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
Mar 10, 2026	Fire safety	Fire Safety Standard	10	Potential harm	—	Open →
Mar 10, 2026	Health	Health Standard	1	Immediate jeopardy	—	Open →
Nov 6, 2024	Fire safety	Fire Safety Standard	9	Potential harm	—	Open →
Nov 6, 2024	Health	Health Complaint, Health Standard	8	Potential harm	—	Open →
Oct 5, 2023	Fire safety	Fire Safety Standard	9	Potential harm	—	Open →
Oct 5, 2023	Health	Health Standard	4	Potential harm	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

No fines or payment denials in the CMS Penalties file for this CCN.

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J1	K·	L·
Actual harm	G·	H·	I·
Potential harm	D20	E12	F8
Minimal	A·	B·	C·

By concept

Date	Tag	Deficiency	Scope / severity	Correction	Flags
Mar 10, 2026	F-0678	Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care	J · Immediate jeopardy Isolated	Corrected Mar 31, 2026
Mar 10, 2026	K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Mar 31, 2026
Mar 10, 2026	K-0293	Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Mar 31, 2026
Mar 10, 2026	K-0324	Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Mar 31, 2026
Mar 10, 2026	K-0345	Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Mar 31, 2026
Mar 10, 2026	K-0351	Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Mar 31, 2026
Mar 10, 2026	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Mar 31, 2026
Mar 10, 2026	K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Mar 31, 2026
Mar 10, 2026	K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Mar 31, 2026
Mar 10, 2026	K-0912	Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Mar 31, 2026
Mar 10, 2026	K-0919	Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Mar 31, 2026
Nov 6, 2024	K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 6, 2024
Nov 6, 2024	K-0293	Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Dec 6, 2024
Nov 6, 2024	K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 6, 2024
Nov 6, 2024	K-0541	Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 6, 2024
Nov 6, 2024	K-0911	Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	K-0919	Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	K-0920	Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	K-0923	Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	F-0684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	F-0686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 6, 2024	Complaint
Nov 6, 2024	F-0687	Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care	E · Potential harm Pattern	Corrected Dec 6, 2024
Nov 6, 2024	F-0688	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. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	F-0698	Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 6, 2024
Nov 6, 2024	F-0804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Dec 6, 2024
Nov 6, 2024	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Dec 6, 2024
Nov 6, 2024	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	F · Potential harm Widespread	Corrected Dec 6, 2024
Oct 5, 2023	K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety	F · Potential harm Widespread	Waiver granted Dec 19, 2023
Oct 5, 2023	K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Oct 23, 2023
Oct 5, 2023	K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 23, 2023
Oct 5, 2023	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 16, 2023
Oct 5, 2023	K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Oct 23, 2023
Oct 5, 2023	K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 18, 2023
Oct 5, 2023	K-0363	Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Oct 18, 2023
Oct 5, 2023	K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 23, 2023
Oct 5, 2023	K-0911	Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Oct 26, 2023
Oct 5, 2023	F-0578	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. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Nov 3, 2023
Oct 5, 2023	F-0758	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. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Nov 3, 2023
Oct 5, 2023	F-0759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Nov 3, 2023
Oct 5, 2023	F-0809	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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Nov 3, 2023

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3.1

Health inspectionsstate 2.8

Staffingstate 3.7

Quality measuresstate 3.2

Long-stay QM

Short-stay QM

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing6.22

State avg 4.25US avg 3.90

Registered nurse (RN)1.85

State avg 0.98US avg 0.69

Licensed practical nurse0.66

State avg 0.65US avg 0.86

Nurse aide3.71

State avg 2.61US avg 2.35

Weekend total nurse5.17

State avg 3.75US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 6.53 (case-mix index 1.33).

Staff turnover

Total nursing staff turnover57.8%

State avg 46.7%US avg 45.3%

Registered nurse turnover28.6%

State avg 40.1%US avg 42.5%

Administrators who left0

State avg 1US avg 1

Health survey score

Cycle 1 standard survey: Mar 10, 2026
Cycle 1 health score: 75
Total weighted score: 74.25

Operating entity

Capitol Lakes Inc

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

Pacific Retirement Services

10 facilities in 5 states. CMS chain ID 391.

VerifiedAssigned by CMS

Chain average overall rating (CMS): 4.6

Ownership disclosures

Disclosures

11

Organizations

3

Individuals

8

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Pacific Retirement Services Inc	Organization	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Apr 1, 2008
Sally Drew	Individual	Corporate officer / director	CORPORATE DIRECTOR	not provided	Oct 10, 2016
Richard Bishop	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Oct 1, 2021
Sue Center	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Jun 21, 2017
Stephen Johannsen	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Jan 16, 2019
Clay Norrbom	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Nov 17, 2017
Harry Peterson	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Jun 21, 2017
Eric Sholty	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	May 27, 2018
Timothy Conroy	Individual	Managing employee	W-2 MANAGING EMPLOYEE	not provided	Mar 23, 2009
Kbc Bank Nv	Organization	Mortgage / security interest	5% OR GREATER SECURITY INTEREST	not provided	Jan 1, 2022
Lapis Municipal Opportunities Fund III LP	Organization	Mortgage / security interest	5% OR GREATER SECURITY INTEREST	not provided	Jan 1, 2022

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 333 W Main St, Madison, WI 53703
ZIP: 53703
County: Dane County FIPS 55025
State: Wisconsin
Urban / rural (CMS): Urban

Within ~25 km

Nearby nursing homes

Facility	Distance	Beds	Last inspection	Citations (window)	Fines
Oak Park Place of Nakoma 4327 Nakoma Rd., Madison, WI 53711 CCN 525729	6.1 km	33	Jan 22, 2026	57	—
Madison Health and Rehabilitation Center 110 Belmont Rd., Madison, WI 53714 CCN 525074	6.5 km	83	Jul 22, 2026	894 IJ5 harm	$289k
Middleton Village Nursing and Rehab 6201 Elmwood Ave, Middleton, WI 53562 CCN 525330	8.7 km	97	Mar 5, 2026	951 IJ3 harm	$68k
Oak Park Nursing and Rehab Center 718 Jupiter Drive, Madison, WI 53718 CCN 525266SFF Candidate	8.7 km	100	Aug 13, 2026	783 IJ2 harm1 open	$44k
Hebron Oaks 510 Genomic Drive, Madison, WI 53719 CCN 525375	10 km	70	Jan 8, 2026	371 IJ	$15k
Complete Care at Maple Grove LLC 3401 Maple Grove Dr., Madison, WI 53719 CCN 525276	11.3 km	184	Jul 2, 2026	1032 IJ4 harm1 open	$154k
Oakwood Village East Health and Rehab Center 5833 American Parkway, Madison, WI 53718 CCN 525692	12.7 km	40	Oct 22, 2025	391 IJ	$212k
Waunakee Valley Senior Living 801 Klein Dr, Waunakee, WI 53597 CCN 525098	14.1 km	84	Apr 9, 2026	562 IJ2 harm	$71k

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	525305	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	525305	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026

Record-level source links for CCN 525305

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction