Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Complete Care at Maple Grove LLC
Madison, WI · 184 certified beds · Last Life Safety survey July 2, 2026
CMS Certification Number 525276 · first certified January 1977
Ownership
Operated by COMPLETE CARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
32 citations — more than 89% 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 9 citations; the earlier surveys on file averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens August 2027 — about 9 months from now. This facility’s last Life Safety survey was July 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 519 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 about three years in Virginia. How the window is measured
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5 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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 32 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
12 physical-environment citations 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 32 Life Safety citations above. The Physical Environment Index
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 | 32 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 2, 2024 | 9 |
| May 5, 2025 | 14 |
| July 2, 2026 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2026-07-02 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-07-02 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2026-07-02 |
| K-0331 | Construct fire resistant interior walls. | 2 | 2025-05-05 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 2 | 2025-05-05 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2026-07-02 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2026-07-02 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-05-05 |
What the citations cover
- Smoke Deficiencies 16
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Emergency Preparedness Deficiencies 4
- Services Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 4 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 2, 2026 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 31, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has plan of correction (October 21, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 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 (August 24, 2026) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 31, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 31, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 24, 2026) |
May 5, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 24, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 24, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 24, 2025) |
| 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 (June 24, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 24, 2025) |
May 2, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 24, 2024) |
| 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 (May 24, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (May 24, 2024) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.