Capitol Lakes Health Center
333 W Main St, Madison, WI 53703 · Dane County · 49 certified beds · avg 26 residents/day · certified since Sep 4, 1979
Part of chain: PACIFIC RETIREMENT SERVICES (10 facilities, chain avg rating 4.6★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 10, 2026 · F-0678
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 31, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (13)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 10, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 5, 2023 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | F |
| 2024 | 8 | 0 | F |
| 2026 | 1 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 7.06 | 4.29 | 3.95 | top 2% in Wisconsin; top 1% in the U.S. |
| Registered Nurse hours | 2.10 | 1.01 | 0.69 | top 3% in Wisconsin; top 2% in the U.S. |
| Weekend total nurse staffing | 5.89 | 3.84 | 3.50 | top 4% in Wisconsin; top 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.01 | 0.68 | 0.48 | top 12% in Wisconsin; top 6% in the U.S. |
| Total nursing staff turnover (%) | 57.3 | 46.9 | 45.8 | bottom 23% in Wisconsin; bottom 21% in the U.S. |
| RN turnover (%) | 25.0 | 39.7 | 42.9 | top 24% in Wisconsin; top 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 6.69, RN 2.00, weekend 5.59. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bishop, Richard | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2021 |
| Center, Sue | Individual | Corporate Officer | NOT APPLICABLE | 06/21/2017 |
| Conroy, Timothy | Individual | W-2 Managing Employee | NOT APPLICABLE | 03/23/2009 |
| Drew, Sally | Individual | Corporate Director | NOT APPLICABLE | 10/10/2016 |
| Johannsen, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 01/16/2019 |
| KBC Bank NV | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 01/01/2022 |
| Lapis Municipal Opportunities Fund III LP | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 01/01/2022 |
| Norrbom, Clay | Individual | Corporate Officer | NOT APPLICABLE | 11/17/2017 |
| Pacific Retirement Services INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2008 |
| Peterson, Harry | Individual | Corporate Officer | NOT APPLICABLE | 06/21/2017 |
| Sholty, Eric | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How is routine foot care handled here, and does a podiatrist visit regularly?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Oak Park Place of Nakoma | 3.8 mi | Madison, WI | ★★★☆☆ | 3/5 | |
| Madison Health and Rehabilitation Center | 4.0 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Middleton Village Nursing and Rehab | 5.4 mi | Middleton, WI | ★☆☆☆☆ | 1/5 | |
| Oak Park Nursing and Rehab Center | 5.4 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Hebron Oaks | 6.2 mi | Madison, WI | ★★★★☆ | 3/5 | |
| Complete Care at Maple Grove LLC | 7.0 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Oakwood Village East Health and Rehab Center | 7.9 mi | Madison, WI | ★★★☆☆ | 2/5 | |
| Badger Prairie HCC | 8.8 mi | Verona, WI | ★★★★★ | 5/5 | |
| Waunakee Valley Senior Living | 8.8 mi | Waunakee, WI | ★★★☆☆ | 2/5 | |
| Four Winds Manor | 9.3 mi | Verona, WI | ★★☆☆☆ | 2/5 | |
| Avina of Sun Prairie | 10.5 mi | Sun Prairie, WI | ★★★★★ | 4/5 | |
| Sun Prairie Senior Living | 11.6 mi | Sun Prairie, WI | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525305.