Complete Care at Maple Grove LLC

Dane · WI · For profit - Corporation · COMPLETE CARE chain · 184 certified beds · CCN 525276 · ST MARYS CARE AND REHAB CENTER LLC


Complete Care at Maple Grove LLC operates 184 certified beds in Madison, Wisconsin. Its Medicare and Medicaid certification dates to 1977-01-01. It averages 110.1 residents a day.

What harm was found in the violations cited at Complete Care at Maple Grove LLC?

CMS lists 82 health-inspection deficiencies for Complete Care at Maple Grove LLC since 2023-02-27, 71 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is J; the most recent health inspection was 2026-07-02.

Survey dateTagDeficiencySeverity
2026-07-02F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2026-07-02F0677Provide care and assistance to perform activities of daily living for any resident who is unable.E
2026-07-02F0554, F0585, F0645, F0684, F0686, F0689, F0690, F0699, F0849Allow residents to self-administer drugs if determined clinically appropriate. / 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. / PASARR screening for Mental disorders or Intellectual Disabilities / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide care or services that was trauma informed and/or culturally competent. / Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D
2026-06-25F0760Ensure that residents are free from significant medication errors.D
2025-07-29F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2025-05-05F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2025-05-05F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2025-05-05F0550, F0761Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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.E
2025-05-05F0554, F0585, F0604, F0656, F0660, F0675, F0677, F0686, F0697Allow residents to self-administer drugs if determined clinically appropriate. / 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. / Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Plan the resident's discharge to meet the resident's goals and needs. / Honor each resident's preferences, choices, values and beliefs. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide safe, appropriate pain management for a resident who requires such services.D
2025-03-28F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2025-03-28F0805, F0842Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2024-11-11F0700Try 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.E
2024-11-11F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2024-10-21F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-10-21F0758Implement 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.D
2024-09-12F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J
2024-09-12F0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.D
2024-06-27F0580, F0585, F0609, F0610, F0686, F0687, F0689, F0755Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide appropriate foot care. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D
2024-05-02F0880Provide and implement an infection prevention and control program.F
2024-05-02F0645, F0679, F0761, F0881PASARR screening for Mental disorders or Intellectual Disabilities / Provide activities to meet all resident's needs. / 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. / Implement a program that monitors antibiotic use.E
2024-05-02F0609, F0610, F0636, F0641, F0684, F0760, F0804, F0883Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. / Ensure each resident receives an accurate assessment. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure that residents are free from significant medication errors. / Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. / Develop and implement policies and procedures for flu and pneumonia vaccinations.D
2024-05-02F0732Post nurse staffing information every day.C
2024-04-10F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E
2024-04-10F0550, F0585, F0657, F0677, F0759Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure medication error rates are not 5 percent or greater.D
2024-01-08F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-01-08F0919Make sure that a working call system is available in each resident's bathroom and bathing area.D
2023-12-04F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J
2023-12-04F0610Respond appropriately to all alleged violations.E
2023-12-04F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D
2023-10-09F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.E
2023-10-09F0609, F0610Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations.D
2023-02-27F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.G
2023-02-27F0812, F0814Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Dispose of garbage and refuse properly.F
2023-02-27F0677, F0725, F0811Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / 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.E
2023-02-27F0585, F0604, F0690, F0757, F0759Honor 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. / Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Ensure medication error rates are not 5 percent or greater.D

Why was Complete Care at Maple Grove LLC fined 6 times?

DateTypeAmount
2025-05-05Fine$58,354
2025-03-28Fine$34,356
2024-10-21Fine$12,048
2024-09-12Fine$15,642
2023-12-04Fine$18,018
2023-12-04Fine$15,239

Has Complete Care at Maple Grove LLC had payment denied by Medicare more than once?

Payment denial startLength in days
2025-06-0321
2024-11-158
2023-12-3048

How is Complete Care at Maple Grove LLC staffed?

MeasureThis facilityWI average
Total nurse staffing hours per resident per day4.968264.21234
Total nursing staff turnover (%)64.046.9
Average number of residents per day110.154.8

Who owns Complete Care at Maple Grove LLC, and what chain is it in?

Complete Care at Maple Grove LLC is registered with CMS as For profit - Corporation, operates under the legal business name ST MARYS CARE AND REHAB CENTER LLC and belongs to the COMPLETE CARE chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTPC WCM OPCO HOLDCO LLCsince 02/28/2025
5% OR GREATER INDIRECT OWNERSHIP INTERESTPC WCM TOPCO LLC, PEACE CAPITAL HOLDINGS II LLC, SMS 2021 TRUSTsince 02/28/2025
INDIRECT OWNERSHIP INTERESTKLUGMAN, JACOB, STEIN, SHALOMsince 02/28/2025
MANAGING CONTROL - GOVERNING BODYHELLMAN, YOSEF, STEIN, SHALOMsince 02/28/2025
CORPORATE OFFICERSTEIN, SHALOMsince 02/28/2025
OPERATIONAL/MANAGERIAL CONTROLCHOLES, DIANA, HELLMAN, YOSEF, MAINA, JENNIFER, MURPHY, SEAN, STERNBUCH, DANIELsince 02/28/2025
TRUSTEE OF THE SNFSTEIN, SHALOMsince 02/28/2025
ADP OF THE SNFDES CAPITAL LLC, JRK INVESTMENTS LLC, PC WCM PROPCO HOLDCO LLC, PC WCM TOPCO LLC, PEACE CAPITAL HOLDINGS II LLC, SMS 2021 TRUST, CHOLES, DIANA, KLUGMAN, JACOB, LEVERENTZ, LUANNE, MAINA, JENNIFER, MURPHY, SEAN, STEIN, SHALOM, STERNBUCH, DANIELsince 02/02/2005

Were you or a family member harmed at Complete Care at Maple Grove LLC?