Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

A
Grade
69
Score
CMS Ratings
16.7/22
Staffing Quality
15.9/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate53.3%
49
Total Beds
26
Occupied
23
Available

Basic Information

Address:

333 W MAIN ST

MADISON, WI 53703

Number of Beds:

49

Estimated Occupancy:

53% (~23 available)

Chain:

PACIFIC RETIREMENT SERVICES

Quality Ratings

Overall Rating:4/5 Stars
Health Inspection:3/5 Stars
Staffing Rating:5/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

525305

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Above Average

This Facility

2.00

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Above Average

This Facility

6.69

hours

National Avg

3.89

hours

Breakdown:

RN: 2.00hLPN: 0.79hAide: 3.91h

Staff Turnover Rate

Annual nursing staff turnover

Above Average

This Facility

57.3%

National Avg

46.6%

RN Turnover: 25.0%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

44

Inspections

4

High

2

Nov 6, 2024 - Health Survey

16 deficiencies cited

Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Dec 6, 2024
Medium - PatternTag F0687

Quality of Life and Care Deficiencies

Provide appropriate foot care.

Corrected: Dec 6, 2024
Medium - PatternTag F0688

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.

Corrected: Dec 6, 2024
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Dec 6, 2024
Medium - PatternTag F0804

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected: Dec 6, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Dec 6, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Dec 6, 2024
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Dec 6, 2024From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Dec 6, 2024
Medium - PatternTag F0687

Quality of Life and Care Deficiencies

Provide appropriate foot care.

Corrected: Dec 6, 2024
Medium - PatternTag F0688

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.

Corrected: Dec 6, 2024
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Dec 6, 2024
Medium - PatternTag F0804

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected: Dec 6, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Dec 6, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Dec 6, 2024
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Dec 6, 2024From Complaint

Oct 5, 2023 - Health Survey

8 deficiencies cited

Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: Nov 3, 2023
Medium - PatternTag F0809

Nutrition and Dietary Deficiencies

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.

Corrected: Nov 3, 2023
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Nov 3, 2023
Medium - PatternTag F0809

Nutrition and Dietary Deficiencies

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.

Corrected: Nov 3, 2023
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Nov 3, 2023
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Nov 3, 2023
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Nov 3, 2023
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: Nov 3, 2023

Jun 21, 2023 - Health Survey

4 deficiencies cited

High - Widespread PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Jul 18, 2023From Complaint
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Jul 18, 2023From Complaint
High - Widespread PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Jul 18, 2023From Complaint
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Jul 18, 2023From Complaint

Aug 11, 2022 - Health Survey

16 deficiencies cited

Low - IsolatedTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 9, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 8, 2022
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Sep 9, 2022
Medium - PatternTag F0583

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Corrected: Sep 9, 2022
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Sep 9, 2022
Medium - PatternTag F0678

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.

Corrected: Sep 9, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 9, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Sep 9, 2022
Low - IsolatedTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 9, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 8, 2022
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Sep 9, 2022
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Sep 9, 2022
Medium - PatternTag F0583

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Corrected: Sep 9, 2022
Medium - PatternTag F0678

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.

Corrected: Sep 9, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 9, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Sep 9, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

No penalties or payment denials in the past 3 years

Key Highlights

High CMS Rating
4 out of 5 stars from Medicare
👨‍⚕
Above Average RN Staffing
2.00 RN hours per resident/day (national avg: 0.64)
🛏
Beds Available
Approximately 23 beds potentially available
🏆
Clean Safety Record
No recent penalties or high-severity deficiencies
🏢
Part of Healthcare Chain
PACIFIC RETIREMENT SERVICES

Frequently Asked Questions

What is the quality rating for CAPITOL LAKES HEALTH CENTER?

CAPITOL LAKES HEALTH CENTER has an overall CMS rating of 4 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

CAPITOL LAKES HEALTH CENTER has 49 certified beds. The facility averages 26 residents per day, with an occupancy rate of approximately 53%.

What type of ownership does this facility have?

This facility is non profit - corporation owned. It is part of the PACIFIC RETIREMENT SERVICES network.

How can I contact CAPITOL LAKES HEALTH CENTER?

You can call CAPITOL LAKES HEALTH CENTER at (608)283-2000. The facility is located at 333 W MAIN ST, MADISON, WI 53703.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: