Complete Care at Maple Grove LLC
Grade D — 62/100 composite score
CMS Star Ratings
Certified Beds
184
Ownership
For profit - Corporation
Total Fines
$95,303
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
PC WCM OPCO HOLDCO LLC
100%
PC WCM TOPCO LLC
PEACE CAPITAL HOLDINGS II LLC
SMS 2021 TRUST
CHOLES, DIANA
HELMAN, YOSEF
MAINA, JENNIFER
MURPHY, SEAN
STERNBUCH, DANIEL
STEIN, SHALOM
Penalties & Fines (8)
| Date | Type | Description | Amount |
|---|---|---|---|
| Mar 28, 2025 | Fine | — | $34,356 |
| Oct 21, 2024 | Fine | — | $12,048 |
| Oct 21, 2024 | Payment Denial | — | — |
| Sep 12, 2024 | Fine | — | $15,642 |
| Dec 4, 2023 | Fine | — | $15,239 |
| Dec 4, 2023 | Fine | — | $18,018 |
| Dec 4, 2023 | Payment Denial | — | — |
| Feb 27, 2023 | Payment Denial | — | — |
Health Inspection Deficiencies (70)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
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.
Resident Rights Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Resident Assessment and Care Planning Deficiencies
Honor each resident's preferences, choices, values and beliefs.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
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.
Pharmacy Service Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care 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.
Pharmacy Service Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
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.
Resident Rights Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies
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.
Pharmacy Service Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
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.
Resident Rights Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies
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.
Resident Rights Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
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Frequently Asked Questions
What is the CareGrader rating for Complete Care at Maple Grove LLC?
Complete Care at Maple Grove LLC in Madison, Wisconsin has a CareGrader grade of D (Below Average), with a composite score of 62.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.
What is the CMS star rating for Complete Care at Maple Grove LLC?
Complete Care at Maple Grove LLC has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.
How many health deficiencies does Complete Care at Maple Grove LLC have?
Complete Care at Maple Grove LLC has 70 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.
Has Complete Care at Maple Grove LLC been fined?
Yes. Complete Care at Maple Grove LLC has $95,303 in total fines from CMS enforcement actions across 8 penalties.
How many beds does Complete Care at Maple Grove LLC have?
Complete Care at Maple Grove LLC has 184 certified beds with approximately 100 current residents (54% occupancy). The facility is located at 3401 Maple Grove Dr., Madison, Wisconsin 53719. It is a for profit - corporation facility.
Data Disclaimer
Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.