Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CAPITOL LAKES HEALTH CENTER
MADISON, WI · 49 certified beds · Last Life Safety survey March 10, 2026
CMS Certification Number 525305 · first certified September 1979
Ownership
Operated by PACIFIC RETIREMENT SERVICES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
28 citations — more than 80% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 10 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens April 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 5, 2023 | 9 |
| November 6, 2024 | 9 |
| March 10, 2026 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-03-10 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2026-03-10 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 2 | 2024-11-06 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-03-10 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 2 | 2026-03-10 |
| K-0919 | Meet requirements for the use of electrical equipment. | 2 | 2026-03-10 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2024-11-06 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2024-11-06 |
What the citations cover
- Smoke Deficiencies 12
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 5
- Services Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 10, 2026 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (March 31, 2026) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (March 31, 2026) |
November 6, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 6, 2024) |
October 5, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Waiver has been granted (December 19, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 26, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.