Wisconsin › Dane County › Madison
Complete Care At Maple Grove LLC
3401 Maple Grove Dr., Madison, WI 53719
Overall★★★★★
Health inspection★★★★★
Staffing★★★★★
Quality measures★★★★★
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Complete Care At Maple Grove LLC is a For-profit, corporation nursing home in Madison, Wisconsin, certified for 184 beds and caring for about 110 residents a day.
CMS gives it 1 of 5 stars overall, below the Wisconsin median of 3; the health inspection rating is 1, staffing 4 and quality measures 4.
Inspectors recorded 82 health deficiencies across the three most recent survey cycles (25, 24, 33 by cycle, most recent first), 7 of them at the actual-harm or immediate-jeopardy level. That is 44.6 per 100 beds, more than the state median of 31.8.
CMS lists 9 penalties in the period covered: fines totalling $154K and 3 payment denials.
Reported nurse staffing is 5.0 hours per resident per day (1.0 RN), close to the Wisconsin median of 4.0; nursing staff turnover is 64.0%.
82health deficiencies, 3 survey cycles7 at actual harm or worse
$154Kfines listed by CMS9 penalties in period
5.0nurse hours per resident per daystate median 4.0
60%occupancy (residents ÷ beds)110 residents a day
Compared with county, state and nation
| Measure | This facility | Dane Co. median | Wisconsin median | US average |
|---|---|---|---|---|
| Overall star rating | 1 | 3 | 3 | 3.0 |
| Health citations, 3 cycles | 82 | 28 | 21 | 28.7 |
| Citations per 100 beds | 44.6 | 43.0 | 31.8 | 26.8 |
| Total nurse hours per resident day | 5.0 | 4.8 | 4.0 | 3.9 |
| RN hours per resident day | 1.0 | 1.1 | 0.9 | 0.7 |
| Nursing staff turnover | 64.0% | 57.8% | 46.2% | 45.8% |
| Fines listed | $153,657 | $15,642 | $0 | — |
County and state figures are medians across facilities (16 in the county, 323 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Wisconsin average per facility for the same cycle, as published by CMS. Standard health survey dates: 5 May 2025, 2 May 2024.
Severity mix: J ×2 G ×5 D ×55 E ×14 F ×5 C ×1
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
Isolated
Pattern
Widespread
Immediate jeopardy
J
K
L
Actual harm
G
H
I
Potential for more than minimal harm
D
E
F
Potential for minimal harm
A
B
C
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 2 Jul 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0699 | Provide care or services that was trauma informed and/or culturally competent. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 2 Jul 2026 | F0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | D | Complaint investigation | Deficient, Provider has no plan of correction |
| 25 Jun 2026 | F0760 | Ensure that residents are free from significant medication errors. | D | Complaint investigation | 23 Jul 2026 |
| 29 Jul 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 12 Aug 2025 |
| 5 May 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0660 | Plan the resident's discharge to meet the resident's goals and needs. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0675 | Honor each resident's preferences, choices, values and beliefs. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 9 Jun 2025 |
| 5 May 2025 | F0697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard survey | 9 Jun 2025 |
| 28 Mar 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint investigation | 26 Apr 2025 |
| 28 Mar 2025 | F0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Complaint investigation | 26 Apr 2025 |
| 28 Mar 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint investigation | 26 Apr 2025 |
| 11 Nov 2024 | F0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | E | Complaint investigation | 23 Nov 2024 |
| 11 Nov 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 23 Nov 2024 |
| 21 Oct 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint investigation | 23 Nov 2024 |
| 21 Oct 2024 | F0758 | 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 | Complaint investigation | 15 Nov 2024 |
| 12 Sep 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 10 Oct 2024 |
| 12 Sep 2024 | F0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D | Complaint investigation | 10 Oct 2024 |
| 27 Jun 2024 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0687 | Provide appropriate foot care. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 19 Jul 2024 |
| 27 Jun 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint investigation | 19 Jul 2024 |
| 2 May 2024 | F0880 | Provide and implement an infection prevention and control program. | F | Complaint investigation | 29 May 2024 |
| 2 May 2024 | F0645 | PASARR screening for Mental disorders or Intellectual Disabilities | E | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0679 | Provide activities to meet all resident's needs. | E | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0881 | Implement a program that monitors antibiotic use. | E | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0641 | Ensure each resident receives an accurate assessment. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0760 | Ensure that residents are free from significant medication errors. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D | Standard survey | 24 May 2024 |
| 2 May 2024 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Complaint investigation | 24 May 2024 |
| 2 May 2024 | F0732 | Post nurse staffing information every day. | C | Complaint investigation | 24 May 2024 |
| 10 Apr 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint investigation | 8 May 2024 |
| 10 Apr 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint investigation | 8 May 2024 |
| 10 Apr 2024 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | Complaint investigation | 8 May 2024 |
| 10 Apr 2024 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint investigation | 8 May 2024 |
| 10 Apr 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint investigation | 8 May 2024 |
| 10 Apr 2024 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint investigation | 8 May 2024 |
| 8 Jan 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint investigation | 16 Feb 2024 |
| 8 Jan 2024 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | Complaint investigation | 17 Jan 2024 |
| 4 Dec 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 16 Feb 2024 |
| 4 Dec 2023 | F0610 | Respond appropriately to all alleged violations. | E | Complaint investigation | 22 Dec 2023 |
| 4 Dec 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 22 Dec 2023 |
| 9 Oct 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Complaint investigation | 23 Oct 2023 |
| 9 Oct 2023 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 23 Oct 2023 |
| 9 Oct 2023 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 2 Nov 2023 |
| 27 Feb 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0814 | Dispose of garbage and refuse properly. | F | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0811 | Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | E | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard survey | 27 Mar 2023 |
| 27 Feb 2023 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Standard survey | 27 Mar 2023 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 5 May 2025 | Payment denial | — | 21 days |
| 5 May 2025 | Fine | $58,354 | |
| 28 Mar 2025 | Fine | $34,356 | |
| 21 Oct 2024 | Payment denial | — | 8 days |
| 21 Oct 2024 | Fine | $12,048 | |
| 12 Sep 2024 | Fine | $15,642 | |
| 4 Dec 2023 | Payment denial | — | 48 days |
| 4 Dec 2023 | Fine | $18,018 | |
| 4 Dec 2023 | Fine | $15,239 |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Wisconsin average. Turnover: nursing staff 64.0%, RNs 60.0%; 0 administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 6.3% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 2.9% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.3% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 6.3% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.3% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 9.2% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.5% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.9% | 14.4% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, corporation. Legal business name: St Marys Care And Rehab Center Llc. Chain: Complete Care (85 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Pc Wcm Opco Holdco LLC | 5% or greater direct ownership interest | 100% | 02/28/2025 |
| Pc Wcm Topco LLC | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 02/28/2025 |
| Des Capital LLC | Adp of the snf | NOT APPLICABLE | 02/28/2025 |
| Jrk Investments LLC | Adp of the snf | NOT APPLICABLE | 02/28/2025 |
| Pc Wcm Propco Holdco LLC | Adp of the snf | NOT APPLICABLE | 02/28/2025 |
| Pc Wcm Topco LLC | Adp of the snf | NOT APPLICABLE | 02/28/2025 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Dane County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Avina of Sun Prairie | Sun Prairie | 50 | 5 | 4 | 2 | 16 | 32.0 | — | 8 Jan 2026 |
| Badger Prairie HCC | Verona | 120 | 5 | 5 | 5 | 9 | 7.5 | — | 10 Sep 2025 |
| Skaalen Nursing and Rehabilitation Center | Stoughton | 70 | 5 | 5 | 5 | 8 | 11.4 | — | 10 Sep 2024 |
| Capitol Lakes Health Center | Madison | 49 | 4 | 3 | 5 | 13 | 26.5 | — | 10 Mar 2026 |
| Hebron Oaks | Madison | 70 | 4 | 3 | 5 | 10 | 14.3 | $15K | 8 Jan 2026 |
| Oak Park Place of Nakoma | Madison | 33 | 3 | 3 | 4 | 30 | 90.9 | — | 22 Jan 2026 |
| Oakwood Village East Health and Rehab Center | Madison | 40 | 3 | 2 | 5 | 16 | 40.0 | $212K | 22 Oct 2025 |
| Sun Prairie Senior Living | Sun Prairie | 52 | 3 | 3 | 2 | 31 | 59.6 | — | 1 Apr 2026 |
All 16 facilities in Dane County
Questions and answers
How many deficiencies has Complete Care At Maple Grove LLC been cited for?
82 health deficiencies across the three most recent survey cycles, 7 at the actual-harm or immediate-jeopardy level. The Wisconsin median is 21 per facility.
Has Complete Care At Maple Grove LLC been fined?
Yes. CMS lists fines totalling $154K in the period covered, plus 3 payment denials.
How does staffing at Complete Care At Maple Grove LLC compare?
Reported total nurse staffing is 5.0 hours per resident per day against a Wisconsin median of 4.0 and a national average of 3.9.
Who operates Complete Care At Maple Grove LLC?
It is part of the Complete Care chain. Ownership type is for-profit, corporation. Organisations in the CMS ownership record include Pc Wcm Opco Holdco LLC and Pc Wcm Topco LLC. Individual owners and managers are not listed on this site.
When was Complete Care At Maple Grove LLC last inspected?
The most recent survey or investigation in the CMS record is dated 2 Jul 2026; the most recent standard health survey was 5 May 2025.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.