Public Record
Complete Care at Maple Grove LLC
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 184
- Avg. residents per day
- 106.1
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 105
- Inspections on file
- 16
- Last inspection
- 2025-07-29
*CMS
*CMS
*CMS
Citations
105 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0675Generalpotential for harm
Honor each resident's preferences, choices, values and beliefs.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0331Generalpotential for harm
Construct fire resistant interior walls.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0919Generalpotential for harm
Meet requirements for the use of electrical equipment.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0912Generalpotential for harm
Have power receptacles that are properly grounded.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0585Generalpotential for harm
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.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0700Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0585Generalpotential for harm
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.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0687Generalpotential for harm
Provide appropriate foot care.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0331Generalpotential for harm
Construct fire resistant interior walls.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0927Generalpotential for harm
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0636Generalpotential for harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0761Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0585Generalpotential for harm
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.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0331Generalpotential for harm
Construct fire resistant interior walls.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0811Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0585Generalpotential for harm
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.
- 0927Generalpotential for harm
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- 0912Generalpotential for harm
Have power receptacles that are properly grounded.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection1 deficiency
- View inspection reportInspection26 deficiencies
- View inspection reportInspection26 deficiencies
- View inspection reportInspection3 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection8 deficiencies
- View inspection reportInspection23 deficiencies
- View inspection reportInspection23 deficiencies
Showing the 10 most recent inspections. 6 earlier inspections are also on record.
FAQ
Questions and answers
- What is Complete Care at Maple Grove LLC?
- Complete Care at Maple Grove LLC is a Medicare- and Medicaid-certified nursing home in Madison, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525276.
- What is the CMS rating for Complete Care at Maple Grove LLC?
- Complete Care at Maple Grove LLC has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Complete Care at Maple Grove LLC have?
- Complete Care at Maple Grove LLC is certified for 184 beds. It serves an average of 106.1 residents per day.
- How many citations does Complete Care at Maple Grove LLC have?
- Complete Care at Maple Grove LLC has 105 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Complete Care at Maple Grove LLC last inspected?
- Complete Care at Maple Grove LLC was last inspected on July 29, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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