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Nursing HomeMedicaid

Capitol Lakes Health Center

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

333 W Main St, Madison, WI 5370349 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
4.1/5

based on 36 Google reviews

5
4
3
2
1
Capitol Lakes Health Center Nursing Home in Madison, WI — Street View
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What this means for your family

Capitol Lakes is highly regarded for its independent living amenities and skilled rehab therapy, making it a strong choice for short-term recovery. However, families should exercise caution regarding the health center; specifically, ask for a clear communication plan and how they secure personal belongings, as these have been recurring points of concern for families.

Google Reviews

Google Reviews

36 reviews on Google
Capitol Lakes is a large Continuing Care Retirement Community that receives high praise from independent living residents for its amenities, downtown location, and dining options. However, the health center and rehab sections have faced serious allegations from family members regarding communication failures, understaffing, and unprofessional conduct, particularly during the COVID-19 pandemic.

Quality Themes

Tap a score for details
Food9.0Staff6.0Clean8.0Activities9.0Meds3.0MemoryN/AComms2.0Value4.0

Strengths

  • High-quality physical therapy and rehab services
  • Excellent dining and restaurant-style meals
  • Prime downtown location with active community life
  • Warm and attentive staff (frequently noted in independent living)

Concerns

  • Poor communication with families regarding resident care (mentioned by 2 reviewers)
  • Allegations of theft or missing personal property (mentioned by 2 reviewers)
  • Understaffing in assisted living and health center areas (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'16(3)'18(5)'20(4)'24(3)'26(2)

Distribution · 40 analyzed

5
29
4
4
3
0
2
0
1
7

How They Respond to Reviews

87%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1Given the facility's downtown location, what specific opportunities do residents have to engage with the broader community or participate in local events?
  • 2I noticed that the health inspection ratings are currently lower than the staffing ratings; what specific steps is the leadership team taking to improve those inspection outcomes?
  • 3How do you ensure consistent and proactive communication with family members regarding a resident's daily health status and care plan updates?
  • 4With the excellent reputation of your physical therapy and rehab services, how are those programs integrated into the daily routine for residents who need ongoing support?
  • 5What protocols do you have in place to ensure the security of residents' personal belongings and property within their rooms?
  • 6I appreciate that you are very active in responding to feedback online; how do you use that family input to make tangible changes to the care environment?

Personalized based on this facility's data


Key Review Excerpts

The physical rehab was top notch, the staff were warm and welcoming and I feel very fortunate to have my rehab at such a 5 star facility.

Rehab patient · 2020★★★★★

I chose Capitol Lakes due to the fact that my surgeons patients chose this facility quite often because they were aware of the surgeons protocol.

Rehab patient · 2023★★★★

The mis communication or lack of is horrible . I would not recommend this rehab place to anyone.

Long-term resident's family · 2020☆☆☆☆
Source: 36 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
2.08hrs
OK
Registered nurses for medical care
Total Nursing
6.48hrs
OK
All nurses + aides combined
Staff Turnover
52%
Lower is better (< 30% = good)
RN Turnover
20%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 15 measures

Medicare Rating
3/ 5
Better Than Avg

11

measures

Worse Than Avg

2

measures

Mixed Results

2

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.7%
Better than Avg
Here
1.7%
US
12.1%
WI
5.2%
Dane
8.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility27.0%
Mixed vs Avgs
Here
27.0%
US
19.4%
WI
25.0%
Dane
28.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility18.6%
Mixed vs Avgs
Here
18.6%
US
19.5%
WI
16.8%
Dane
11.6%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
WI
95.6%
Dane
95.2%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility21.6%
Worse than Avg
Here
21.6%
US
15.5%
WI
15.9%
Dane
15.5%
🩺

Residents with a long-term catheter

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
0.9%
WI
2.2%
Dane
4.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility98.5%
Better than Avg
Here
98.5%
US
79.8%
WI
82.2%
Dane
87.1%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.6%
Better than Avg
Here
99.6%
US
81.8%
WI
86.6%
Dane
87.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.1%
Better than Avg
Here
1.1%
US
1.6%
WI
1.3%
Dane
1.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

1deficiencies
Well below state avg (9.8)
3 complaint-triggered

Capitol Lakes Health Center shows persistent deficiencies across care areas including fire safety, medication management, and care quality, with families filing complaints about pain management and pressure ulcer care. The facility has 48 deficiencies across 4 surveys, with recurring issues in fire safety systems and electrical compliance appearing in multiple inspections despite reported corrections, suggesting ongoing operational challenges.

Mar 10, 2026Routine
11
0678Immediate jeopardy · IsolatedCorrected

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.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0293Potential for harm · PatternCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0351Potential for harm · PatternCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0912Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

0223Potential for harm · IsolatedCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0521Potential for harm · IsolatedCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Nov 6, 2024Routine
16
0804Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0687Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate foot care.

0223Potential for harm · PatternCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0541Potential for harm · PatternCorrected

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0688Potential for harm · IsolatedCorrected

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.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0911Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nov 6, 2024Complaint
1
0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Oct 5, 2023Routine
13
0131Potential for harm · Widespread

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

0809Potential for harm · WidespreadCorrected

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.

0354Potential for harm · WidespreadCorrected

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

0211Potential for harm · PatternCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0911Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0578Potential for harm · IsolatedCorrected

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.

0758Potential for harm · IsolatedCorrected

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.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0362Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Jun 21, 2023Complaint
2
0580Actual harm · IsolatedCorrected

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.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Ownership & Operations

Who Operates This Facility

Owner / Operator

Capitol Lakes Health Center

Organization Type

nonprofit

Chain Affiliation

Chain Name

Pacific Retirement Services

Chain Size

10 facilities nationwide

Chain avg rating: 4.6/5 · Rank 9 of 10 (Worst)

Ownership & Management

Key personnel

Kbc Bank Nv5% or Greater Security InterestLapis Municipal Opportunities Fund III Lp5% or Greater Security InterestConroy, TimothyW-2 Managing EmployeeDrew, SallyOfficer / DirectorBishop, RichardOfficer / Director
Source: Medicare provider data

Contact

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References & Resources

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