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Data / Nursing homes / Wisconsin / Complete Care at Maple Grove LLC

Complete Care at Maple Grove LLC, Madison, WI: 1 star rating, fined $153,657 across 6 fines and had 3 payment denials

Complete Care at Maple Grove LLC in Madison, WI is owned by PC WCM OPCO HOLDCO LLC, is rated 1 of 5 stars by Medicare, and was fined $153,657 across 6 fines and had 3 payment denials in the three years to October 1, 2026. CMS lists 71 health citations from inspections in that time, the latest survey on July 2, 2026, and 6 of them found actual harm or immediate jeopardy.

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Address
3401 Maple Grove Dr., Madison, WI 53719
Overall rating
1 of 5 stars
Health inspection rating
1 of 5
Staffing rating
4 of 5
Quality measure rating
4 of 5
Certified beds
184
Residents per day
104 on average
Ownership type
For profit, corporation
Legal business name
St Marys Care and Rehab Center LLC
Chain
Complete Care, 85 facilities
Fines
$153,657 across 6 fines, three years to October 1, 2026
Payment denials
3
Health citations
71, of which 6 with actual harm or immediate jeopardy
Latest survey
July 2, 2026
CMS Certification Number
525276
On Care Compare
Medicare Care Compare

Fines and payment denials

Every fine and payment denial CMS lists for this facility in the three years, newest first.

DateTypeFine amountDenial startsDenial daysSource
May 5, 2025Fine$58,354Not listeddata.cms.gov
May 5, 2025Payment denialNot listedJune 3, 202521data.cms.gov
March 28, 2025Fine$34,356Not listeddata.cms.gov
October 21, 2024Fine$12,048Not listeddata.cms.gov
October 21, 2024Payment denialNot listedNovember 15, 20248data.cms.gov
September 12, 2024Fine$15,642Not listeddata.cms.gov
December 4, 2023Fine$18,018Not listeddata.cms.gov
December 4, 2023Fine$15,239Not listeddata.cms.gov
December 4, 2023Payment denialNot listedDecember 30, 202348data.cms.gov

Recent health citations

Citations from health inspections, newest first.

Survey dateTagWhat CMS citedScope and severityStatusCorrected onSource
July 2, 2026F849Arrange 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: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F: widespread, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F699Provide care or services that was trauma informed and/or culturally competent.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F677Provide care and assistance to perform activities of daily living for any resident who is unable.E: pattern, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F645PASARR screening for Mental disorders or Intellectual DisabilitiesD: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F585Honor 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
July 2, 2026F554Allow residents to self-administer drugs if determined clinically appropriate.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 31, 2026data.cms.gov
June 25, 2026F760Ensure that residents are free from significant medication errors.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 23, 2026data.cms.gov
July 29, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D: isolated, no actual harm, potential for more than minimal harmCorrectedAugust 12, 2025data.cms.gov
May 5, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G: isolated, actual harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F: widespread, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F761Ensure 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: pattern, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F697Provide safe, appropriate pain management for a resident who requires such services.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F675Honor each resident's preferences, choices, values and beliefs.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F660Plan the resident's discharge to meet the resident's goals and needs.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F585Honor 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F554Allow residents to self-administer drugs if determined clinically appropriate.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
May 5, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E: pattern, no actual harm, potential for more than minimal harmCorrectedJune 9, 2025data.cms.gov
March 28, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G: isolated, actual harmCorrectedApril 26, 2025data.cms.gov
March 28, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D: isolated, no actual harm, potential for more than minimal harmCorrectedApril 26, 2025data.cms.gov
March 28, 2025F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.D: isolated, no actual harm, potential for more than minimal harmCorrectedApril 26, 2025data.cms.gov
November 11, 2024F700Try 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: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 23, 2024data.cms.gov
November 11, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 23, 2024data.cms.gov
October 21, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G: isolated, actual harmCorrectedNovember 23, 2024data.cms.gov
October 21, 2024F758Implement 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: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 15, 2024data.cms.gov
September 12, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J: isolated, immediate jeopardyCorrectedOctober 10, 2024data.cms.gov
September 12, 2024F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.D: isolated, no actual harm, potential for more than minimal harmCorrectedOctober 10, 2024data.cms.gov
June 27, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F687Provide appropriate foot care.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F610Respond appropriately to all alleged violations.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F585Honor 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
June 27, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 19, 2024data.cms.gov
May 2, 2024F883Develop and implement policies and procedures for flu and pneumonia vaccinations.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F881Implement a program that monitors antibiotic use.E: pattern, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F880Provide and implement an infection prevention and control program.F: widespread, no actual harm, potential for more than minimal harmCorrectedMay 29, 2024data.cms.gov
May 2, 2024F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F761Ensure 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: pattern, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F760Ensure that residents are free from significant medication errors.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F732Post nurse staffing information every day.C: widespread, minimal harm potentialCorrectedMay 24, 2024data.cms.gov
May 2, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F679Provide activities to meet all resident's needs.E: pattern, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F645PASARR screening for Mental disorders or Intellectual DisabilitiesE: pattern, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F641Ensure each resident receives an accurate assessment.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F610Respond appropriately to all alleged violations.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
May 2, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 24, 2024data.cms.gov
April 10, 2024F759Ensure medication error rates are not 5 percent or greater.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 8, 2024data.cms.gov
April 10, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E: pattern, no actual harm, potential for more than minimal harmCorrectedMay 8, 2024data.cms.gov
April 10, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 8, 2024data.cms.gov
April 10, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 8, 2024data.cms.gov
April 10, 2024F585Honor 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 8, 2024data.cms.gov
April 10, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 8, 2024data.cms.gov
January 8, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G: isolated, actual harmCorrectedFebruary 16, 2024data.cms.gov
January 8, 2024F919Make sure that a working call system is available in each resident's bathroom and bathing area.D: isolated, no actual harm, potential for more than minimal harmCorrectedJanuary 17, 2024data.cms.gov
December 4, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J: isolated, immediate jeopardyCorrectedFebruary 16, 2024data.cms.gov
December 4, 2023F610Respond appropriately to all alleged violations.E: pattern, no actual harm, potential for more than minimal harmCorrectedDecember 22, 2023data.cms.gov
December 4, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 22, 2023data.cms.gov
October 9, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.E: pattern, no actual harm, potential for more than minimal harmCorrectedOctober 23, 2023data.cms.gov
October 9, 2023F610Respond appropriately to all alleged violations.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 2, 2023data.cms.gov
October 9, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D: isolated, no actual harm, potential for more than minimal harmCorrectedOctober 23, 2023data.cms.gov

Owners and managers

Organizations CMS lists as owners or managers of this facility, as CMS names them. CMS also lists 18 individual or personal trusts (2 owners, 7 managers, 2 officers, directors or trustees, 7 other disclosable parties). Their names are not shown on this page.

OrganizationRoleShareSinceSource
PC WCM OPCO HOLDCO LLCDirect owner100%February 28, 2025data.cms.gov
PC WCM Topco LLCIndirect ownerNot listedFebruary 28, 2025data.cms.gov
Peace Capital Holdings II LLCIndirect ownerNot listedFebruary 28, 2025data.cms.gov
SMS 2021 TrustIndirect ownerNot listedFebruary 28, 2025data.cms.gov
Des Capital LLCAdditional disclosable partyNot listedFebruary 28, 2025data.cms.gov
JRK Investments LLCAdditional disclosable partyNot listedFebruary 28, 2025data.cms.gov
PC WCM PROPCO HOLDCO LLCAdditional disclosable partyNot listedFebruary 28, 2025data.cms.gov
PC WCM Topco LLCAdditional disclosable partyNot listedFebruary 28, 2025data.cms.gov
Peace Capital Holdings II LLCAdditional disclosable partyNot listedFebruary 28, 2025data.cms.gov
SMS 2021 TrustAdditional disclosable partyNot listedFebruary 28, 2025data.cms.gov

Also on SpecStream

Updated November 7, 2026. Read from CMS Provider Data Catalog, nursing homes. Open data from the Centers for Medicare & Medicaid Services (US government work). Fines and citations are as CMS lists them on the date this page was read and can change after an appeal. The CMS files are joined on the CMS Certification Number. CMS gives owners no ID, so an owner page groups facilities by the owner name as CMS spells it. Names of individual owners and managers are not shown. This page uses CMS data and is not endorsed or certified by CMS. Free to reuse with credit to SpecStream under CC BY 4.0. Spot a wrong value? Write to [email protected] with the link to this page.