Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- WisconsinAbove only 22% of peers321 rated homes · average 3.0★
- Dane CountyAbove only 36% of peers15 rated homes · average 2.3★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs WI avg
- StaffingCan add or remove a star4★+0.3 vs WI avg
- Quality measuresCan add or remove a star4★+0.9 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.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersWI avg2.8★U.S. avg2.8★
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.
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★
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.
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 assessments4★Above 58% of peersWI avg3.1★U.S. avg3.6★
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.
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 staff5.63hrsTop 5%WI avg4.19Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
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 only1.82hrsTop 2%WI avg0.96Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
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 turnover81%
The share of nursing staff who left within the past year, from the same payroll data.
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$0Above only 42% of peersWI avg$41,875Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMay 2022 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 23, 2025Cycle 1worst D · no actual harm
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jan 9, 2026
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 9, 2026
Dec 3, 2025Cycle 1worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Dec 19, 2025
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Dec 19, 2025
Jan 15, 2025Cycle 2worst E · no actual harm
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Feb 15, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 15, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Feb 15, 2025
Sep 18, 2024Cycle 1worst F · no actual harm
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Oct 30, 2024
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Oct 30, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Oct 30, 2024
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Oct 30, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Oct 30, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Oct 30, 2024
- 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 Oct 30, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 30, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 30, 2024
Jul 20, 2023Cycle 2worst F · no actual harm
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareD · isolatedCorrected Aug 20, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Aug 20, 2023
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationC · widespreadCorrected Aug 20, 2023
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationF · widespreadCorrected Aug 20, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 20, 2023
- 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 Aug 20, 2023
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 20, 2023
May 11, 2022Cycle 3worst D · no actual harm
- 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 Jun 2, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined5.63hrs
- Registered nursesRN hours only1.82hrs
- Licensed practical nursesLPN hours0.29hrs
- Nurse aidesCNA hours3.52hrs
- Weekend nursingAll staff on Saturdays and Sundays4.85hrs
- 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 only81%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy33 certified beds · ~20 residents a day61%Above only 23% of peersWI avg 73%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $41,875WI avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Helle Revocable Trust
- Lakleland Nakoma LLC
- Byron Chase
- Scott Frank
- Scott Frank
Person Organization
Sources & notes
Public data, updated quarterlyData 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 525729 · 4327 Nakoma Rd., Madison, WI, 53711.
- 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.
