Capitol Lakes Health Center
333 W Main St, Madison, WI 53703
Capitol Lakes Health Center is a nursing home in Madison, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (608) 283-2000
- Last standard health inspection
- March 10, 2026 (8 months ago)
- Certified beds
- 49
- Residents per day, on average
- 29.4
- Ownership type
- Non profit - Corporation
- Legal business name
- Capitol Lakes INC.
- Chain
- Pacific Retirement Services
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (13 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 7.8 to 6.5 hours per resident per day.
1 citation
Health inspection on March 10, 2026
CMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
Citation F0678. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on March 31, 2026.
10 citations
Fire safety inspection on March 10, 2026
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 31, 2026.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on March 31, 2026.
CMS has cited this home for K0293 2 times since 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on March 31, 2026.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on March 31, 2026.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on March 31, 2026.
CMS has cited this home for K0372 2 times since 2024.
Citation K0912. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on March 31, 2026.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on March 31, 2026.
CMS has cited this home for K0223 2 times since 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 31, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on March 31, 2026.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on March 31, 2026.
CMS has cited this home for K0919 2 times since 2024.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
8 citations
Health inspection on November 6, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on December 6, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 6, 2024.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 6, 2024.
Citation F0687. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on December 6, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 6, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 6, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 6, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on December 6, 2024.
9 citations
Fire safety inspection on November 6, 2024
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 6, 2024.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on December 6, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 6, 2024.
Citation K0541. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on December 6, 2024.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on December 6, 2024.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on December 6, 2024.
CMS has cited this home for K0911 2 times since 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on December 6, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 6, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on December 6, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 5.8 to 5.0 hours per resident per day.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
4 citations
Health inspection on October 5, 2023
CMS lists this as a standard inspection.
Citation F0809. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 3, 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 3, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 3, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on November 3, 2023.
9 citations
Fire safety inspection on October 5, 2023
CMS lists this as a standard inspection.
Citation K0131. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for sections of health care facilities separated by fire resistive construction.
CMS lists it as corrected on December 19, 2023.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on October 23, 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on October 23, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on October 18, 2023.
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on October 26, 2023.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 23, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 16, 2023.
Citation K0362. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on October 18, 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on October 23, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- PACIFIC RETIREMENT SERVICES INCOperational/managerial control · not applicable · since 04/01/2008
Questions
When was Capitol Lakes Health Center last inspected?
CMS lists March 10, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Capitol Lakes Health Center have?
CMS lists 13 health citations since October 5, 2023. CMS also calls these deficiencies.
Has Capitol Lakes Health Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Capitol Lakes Health Center?
Its CMS overall star rating is 4 of 5.
Is Capitol Lakes Health Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.