Capitol Lakes Health Center

Capitol Lakes Health Center was recognized and ceritified in 1979 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Capitol Lakes Health Center which is located in 333 W Main St Madison, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Capitol Lakes Health Center is being offered ceritified services and products in Wisconsin.
Address:   333 W Main St
       Madison, WI 53703

Phone:   (608) 283-2100

County: Dane
Federal Provider Number: 525305
Participates in: Medicare And Medicaid
Certified Date: Tuesday, September 4, 1979 (45 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Capitol Lakes Inc.
Ownership Type: Non Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationUs Bank National Association5% Or Greater Mortgage Interest
OrganizationSovereign Bank5% Or Greater Security Interest
OrganizationSovereign Bank5% Or Greater Mortgage Interest
OrganizationPacific Retirement ServicesOperational/managerial Control
OrganizationKbc Bank Nv5% Or Greater Security Interest
OrganizationKbc Bank Nv5% Or Greater Mortgage Interest
OrganizationUs Bank National Association5% Or Greater Security Interest
PersonKristin VayerW-2 Managing Employee
PersonBrian PurtellDirector/officer
PersonLenton MerrymanDirector/officer
PersonBrian MclemoreOperational/managerial Control
PersonTimothy ConroyW-2 Managing Employee
PersonPaula BonnerDirector/officer
PersonLarry BoeckDirector/officer

Provider Resides in Hospital: No
Number of Federally Certified Beds: 85
Number of Residents in Federally Certified Beds: 80 (95% occupied)
Continuing Care Retirement Community: Yes
Special Focus Facility: No
With a Resident and Family Council: Resident
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Tuesday, July 1, 2014
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 1, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, July 1, 2014
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 1, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Monday, May 19, 2014
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, June 19, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, January 7, 2014
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0285 (Coordinate assessments with the pre-admission screening and resident review program for mentally-ill)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 1, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, October 30, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, October 30, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0362 (Hire sufficient dietary support personnel.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, October 30, 2013
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, October 30, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0071 (Properly constructed linen or trash chutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0075 (Properly sized and located linen or trash receptacles.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0070 (Restrictions on the use of portable space heaters.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0019 (Properly constructed windows in hallway walls or doors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 29, 2013
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 29, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 25, 2013
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, July 25, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, July 25, 2013
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, July 25, 2013
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: J
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, September 5, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0356 (Post nurse staffing information/data on a daily basis.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0167 (Allow residents to easily view the results of the nursing home's most recent inspection.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0164 (Keep residents' personal and medical records private and confidential.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0518 (Train all employees on what to do in an emergency, and carry out unannounced staff drills.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0372 (Dispose of garbage and refuse properly.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 2, 2012
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, September 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0011 (A two-hour-resistant firewall separation.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Tuesday, December 4, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 31, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, July 25, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 17, 2012
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 28, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 24, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, February 21, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, January 24, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, February 21, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, May 10, 2011
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, May 10, 2011
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, May 10, 2011
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, May 10, 2011
Survey Type: Health
Deficiency: F0327 (Give each resident enough fluids to keep them healthy and prevent dehydration.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, May 10, 2011
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, May 10, 2011
Survey Type: Health
Deficiency: F0386 (Make sure that doctors see a resident's plan of care at every visit and make notes about progress an)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0154 (Back-up procedures in place for a faulty automatic sprinkler system.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0155 (An approved back-up procedure for a faulty fire alarm system.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, April 25, 2011
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 31, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 1
Number of Substantiated Complaints: 5
Number of Fines: 2
Number of Payment Denials: 0
Total Number of Penalties: 2
Total Amount of Fines in Dollars: USD 12,960


Date of inspection that triggered the penalty: Tuesday, January 24, 2012
Penalty Type: Fine
Fine Amount: 5,460

Date of inspection that triggered the penalty: Thursday, August 2, 2012
Penalty Type: Fine
Fine Amount: 7,500
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (1 out of 5 stars)
Quality Rating (4 out of 5 stars)
Staffing Rating (4 out of 5 stars)
RN Staffing Rating (4 out of 5 stars)
Overall Rating (2 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
4%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
9%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
15%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
4%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
5%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
21%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
98%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
96%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
6%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
7%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
15%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
44%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
91%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
1%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
90%
84%

N/A
Data not available.

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Capitol Lakes Health Center [Federal No:525305] near 333 W Main St, Madison WI

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