CAPITOL LAKES HEALTH CENTER
333 W MAIN ST
MADISON, WI, 53703
6082832000
CCN: 525305
3
Overall2
Health5
Staffing4
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| LAPIS MUNICIPAL OPPORTUNITIES FUND III LP | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE |
| KBC BANK NV | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE |
| DREW, SALLY | CORPORATE DIRECTOR | NOT APPLICABLE |
| JOHANNSEN, STEPHEN | CORPORATE OFFICER | NOT APPLICABLE |
| PETERSON, HARRY | CORPORATE OFFICER | NOT APPLICABLE |
| SHOLTY, ERIC | CORPORATE OFFICER | NOT APPLICABLE |
| NORRBOM, CLAY | CORPORATE OFFICER | NOT APPLICABLE |
| BISHOP, RICHARD | CORPORATE OFFICER | NOT APPLICABLE |
| CENTER, SUE | CORPORATE OFFICER | NOT APPLICABLE |
| PACIFIC RETIREMENT SERVICES INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| CONROY, TIMOTHY | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Health Deficiencies (22)
2024-11-06 · Health
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F688 · 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.
E
F687 · Quality of Life and Care Deficiencies
Provide appropriate foot care.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2023-10-05 · Health
F
F809 · 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.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F758 · 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.
D
F578 · 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.
2023-06-21 · Health
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
G
F580 · 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.
2022-08-11 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
B
F842 · 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.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F678 · 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.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
7.79
RN Hrs/Resident/Day0.54
2.02
LPN Hrs/Resident/Day0.81
0.78
CNA Hrs/Resident/Day2.33
4.98
PT Hrs/Resident/Day0.12
0.06
Data as of 2026-03-01