Capitol Lakes Health Center
333 W Main St · Madison, WI · 53703 · 6082832000
49 certified beds Non profit - Corporation Chain: Pacific Retirement Services
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Staffing hours comfortably above national benchmarks.
- No federal fines or payment denials in CMS’s 3-year window.
The composite number cleared 71 points, but Recommended is gated: inspection record below the Recommended bar; immediate-jeopardy citation in the current inspection cycle. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 5 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 6.48 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 2.08 | 0.55–0.75 |
| Weekend hours / resident-day | 5.41 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (15 in the current record)
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Immediate jeopardy · J March 10, 2026
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 March 31, 2026 · Quality of Life and Care
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Potential for harm · D November 6, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 6, 2024 · Quality of Life and Care
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Potential for harm · E November 6, 2024
Provide appropriate foot care.
Corrected December 6, 2024 · Quality of Life and Care
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Potential for harm · D November 6, 2024
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 December 6, 2024 · Quality of Life and Care
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Potential for harm · D November 6, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected December 6, 2024 · Quality of Life and Care
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Potential for harm · F November 6, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected December 6, 2024 · Nutrition and Dietary
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Potential for harm · F November 6, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 6, 2024 · Nutrition and Dietary
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Potential for harm · F November 6, 2024
Provide and implement an infection prevention and control program.
Corrected December 6, 2024 · Infection Control
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Potential for harm · D November 6, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 6, 2024 · Quality of Life and Care
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Potential for harm · D October 5, 2023
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 November 3, 2023 · Resident Rights
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Potential for harm · D October 5, 2023
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 November 3, 2023 · Pharmacy Service
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Potential for harm · D October 5, 2023
Ensure medication error rates are not 5 percent or greater.
Corrected November 3, 2023 · Pharmacy Service
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Potential for harm · F October 5, 2023
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 November 3, 2023 · Nutrition and Dietary
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Actual harm · G June 21, 2023 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected July 18, 2023 · Resident Rights
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Potential for harm · D June 21, 2023 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected July 18, 2023 · Quality of Life and Care
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525305 · certified since September 4, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.