Map showing the location of Complete Care at Maple Grove LLC in Madison, Wisconsin
3401 Maple Grove Dr., Madison, WI, 53719

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinLowest tier among peers321 rated homes · average 3.0★
  • Dane CountyLowest tier among peers15 rated homes · average 2.3★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs WI avg
  • StaffingCan add or remove a star4★+0.3 vs WI avg
  • Quality measuresCan add or remove a star3★−0.1 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Ownership changed in the last 12 monthsRatings reflect performance under previous and current owners. Ask how staffing and management changed after the sale.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 35% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 33% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.94hrsAbove 84% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.16hrsAbove 76% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better73%Above only 5% of peersWI avg48%RN turnover71%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$95,303Above only 16% of peersWI avg$41,875Fines · denials5 · 3
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
70citations
13inspection dates
5actual harm (G–I)
2immediate jeopardy (J–L)
Jul 29, 2025most recent

Citations by monthFeb 2023 – Jul 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jul 29, 20251 citationCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 12, 2025
May 5, 202513 citationsCycle 1worst G · actual harm
  1. F761Ensure 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 ServiceE · patternCorrected Jun 9, 2025
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jun 9, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jun 9, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jun 9, 2025
  5. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 9, 2025
  6. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jun 9, 2025
  7. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jun 9, 2025
  8. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jun 9, 2025
  9. F585Honor 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 RightsD · isolatedCorrected Jun 9, 2025
  10. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 9, 2025
  11. F656Develop 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 PlanningD · isolatedCorrected Jun 9, 2025
  12. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Jun 9, 2025
  13. F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareD · isolatedCorrected Jun 9, 2025
Mar 28, 20253 citationsCycle 1worst G · actual harm$34,356
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Apr 26, 2025
  2. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Apr 26, 2025
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2025
Nov 11, 20242 citationsCycle 2worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 23, 2024
  2. F700Try 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 CareE · patternCorrected Nov 23, 2024
Oct 21, 20242 citationsCycle 2worst G · actual harm$12,048, payment denial
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 23, 2024
  2. F758Implement 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 ServiceD · isolatedCorrected Nov 15, 2024
Sep 12, 20242 citationsCycle 2worst J · immediate jeopardy$15,642
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Oct 10, 2024
  2. F947Ensure 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 ServicesD · isolatedCorrected Oct 10, 2024
Jun 27, 20248 citationsCycle 2worst D · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 19, 2024
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 19, 2024
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 19, 2024
  4. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jul 19, 2024
  5. F585Honor 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 RightsD · isolatedCorrected Jul 19, 2024
  6. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 19, 2024
  7. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 19, 2024
  8. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Jul 19, 2024
May 2, 202414 citationsCycle 2worst F · no actual harm
  1. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected May 24, 2024
  2. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected May 24, 2024
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 24, 2024
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 24, 2024
  5. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 24, 2024
  6. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 24, 2024
  7. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected May 24, 2024
  8. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected May 24, 2024
  9. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected May 24, 2024
  10. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected May 24, 2024
  11. F761Ensure 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 ServiceE · patternCorrected May 24, 2024
  12. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected May 29, 2024
  13. F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected May 24, 2024
  14. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected May 24, 2024
Apr 10, 20246 citationsCycle 2worst E · no actual harm
  1. F585Honor 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 RightsD · isolatedCorrected May 8, 2024
  2. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected May 8, 2024
  3. F657Develop 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 PlanningD · isolatedCorrected May 8, 2024
  4. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 8, 2024
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 8, 2024
  6. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected May 8, 2024
Jan 8, 20242 citationsCycle 3worst G · actual harm
  1. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Jan 17, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Feb 16, 2024
Dec 4, 20233 citationsCycle 3worst J · immediate jeopardy$18,018, $15,239, payment denial
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 22, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Feb 16, 2024
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 22, 2023
Oct 9, 20233 citationsCycle 3worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Oct 23, 2023
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 23, 2023
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 2, 2023
Feb 27, 202311 citationsCycle 3worst G · actual harmpayment denial
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 27, 2023
  2. F585Honor 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 RightsD · isolatedCorrected Mar 27, 2023
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 27, 2023
  4. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 27, 2023
  5. F690Provide 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 CareD · isolatedCorrected Mar 27, 2023
  6. F725Provide 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 ServicesE · patternCorrected Mar 27, 2023
  7. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 27, 2023
  8. F811Ensure 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 DietaryE · patternCorrected Mar 27, 2023
  9. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Mar 27, 2023
  10. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 27, 2023
  11. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Mar 27, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.94hrsAbove 84% of peers+0.75 vs WI avg
  • Registered nursesRN hours only1.16hrsAbove 76% of peers+0.20 vs WI avg
  • Licensed practical nursesLPN hours0.66hrs
  • Nurse aidesCNA hours3.12hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.57hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better73%Above only 5% of peersWI avg 48%
  • RN turnoverRegistered nurses only71%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy184 certified beds · ~101 residents a day55%Above only 13% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $95,303In fines
  • 5Fines
  • 3Payment denials
  • $41,875WI avg in fines
Above only 16% of peersFewer fines than 16% of rated homes in Wisconsin

Actions on record

  1. Mar 28, 2025Civil money penalty$34,356
  2. Oct 21, 2024Civil money penalty$12,048
  3. Oct 21, 2024Denial of payment for new admissionsfrom Nov 15, 2024
  4. Sep 12, 2024Civil money penalty$15,642
  5. Dec 4, 2023Civil money penalty$18,018
  6. Dec 4, 2023Civil money penalty$15,239
  7. Dec 4, 2023Denial of payment for new admissionsfrom Dec 30, 2023
  8. Feb 27, 2023Denial of payment for new admissionsfrom Mar 28, 2023

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Complete Care85 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
Changed hands in the last 12 months

People and entities on file

Direct owners (5%+)
  • Pc Wcm Opco Holdco LLC
Indirect owners (5%+)
  • Pc Wcm Topco LLC
  • Peace Capital Holdings II LLC
  • Sms 2021 Trust
Operational or managerial control
  • Diana Choles
  • Yosef Helman
  • Jennifer Maina
  • Sean Murphy
  • Daniel Sternbuch
Corporate officers
  • Shalom Stein

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525276 · 3401 Maple Grove Dr., Madison, WI, 53719.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Dane County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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