Complete Care at Maple Grove LLC
Nursing Home · Madison, WI
CMS certification number525276
Contact & location
3401 Maple Grove Dr.Madison, WI 53719
Dane County
- Phone
- (608) 845-1000
- ZIP code
- 53719 – all care providers
Facility details
- Certified beds
- 184
- Residents per day
- 110.1 (60% occupied)
- Ownership
- For profit - Corporation
- Legal name
- ST Marys Care and Rehab Center LLC
- Chain
- Complete Care (85 facilities, avg 3.1★)
- Medicare certified since
- January 1, 1977
- Participates in
- Medicare and Medicaid
- Council
- Both council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- 4.97 (state 4.21 · U.S. 3.86)
- Registered nurses (RN)
- 1.04 (state 0.99 · U.S. 0.69)
- Licensed practical nurses
- 0.70 (state 0.64 · U.S. 0.86)
- Nurse aides
- 3.23 (state 2.58 · U.S. 2.32)
- Weekend total
- 4.46 (state 3.77 · U.S. 3.42)
- Nursing staff turnover
- 64.0 (state 46.9 · U.S. 45.8)%
- RN turnover
- 60.0 (state 39.7 · U.S. 42.9)%
- Administrators who left
- 0 in the last year
Inspections
- Last standard inspection
- May 5, 2025
- Health deficiencies (last cycle)
- 25.0 (state 9.5 · U.S. 9.3)
- From complaints
- 12
- Citations on record (3 years)
- 57 health · 23 fire safety · includes immediate jeopardy
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2026-07-02 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies · complaint inspection |
F No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Allow residents to self-administer drugs if determined clinically appropriate. F0554 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | 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. F0585 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | PASARR screening for Mental disorders or Intellectual Disabilities F0645 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | Provide care or services that was trauma informed and/or culturally competent. F0699 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-07-02 | 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. F0849 · Administration Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Deficient, Provider has no plan of correction |
| 2026-06-25 | Ensure that residents are free from significant medication errors. F0760 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-07-23 |
| 2025-07-29 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-08-12 |
| 2025-05-05 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies |
G Actual harm |
Corrected 2025-06-09 |
| 2025-05-05 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
F No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550 · Resident Rights Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | 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. F0761 · Pharmacy Service Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Allow residents to self-administer drugs if determined clinically appropriate. F0554 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | 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. F0585 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. F0604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Plan the resident's discharge to meet the resident's goals and needs. F0660 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Honor each resident's preferences, choices, values and beliefs. F0675 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-05-05 | Provide safe, appropriate pain management for a resident who requires such services. F0697 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-09 |
| 2025-03-28 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
Corrected 2025-04-26 |
| 2025-03-28 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. F0805 · Nutrition and Dietary Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-04-26 |
| 2025-03-28 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-04-26 |
| 2024-11-11 | 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. F0700 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-11-23 |
| 2024-11-11 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-11-23 |
| 2024-10-21 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
Corrected 2024-11-23 |
| 2024-10-21 | 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. F0758 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-11-15 |
| 2024-09-12 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
Corrected 2024-10-10 |
| 2024-09-12 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. F0947 · Nursing and Physician Services Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-10-10 |
| 2024-06-27 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | 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. F0585 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | Respond appropriately to all alleged violations. F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | Provide appropriate foot care. F0687 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-27 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-05-02 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
F No actual harm, potential for more than minimal harm |
Corrected 2024-05-29 |
| 2024-05-02 | PASARR screening for Mental disorders or Intellectual Disabilities F0645 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-05-24 |
| 2024-05-02 | Provide activities to meet all resident's needs. F0679 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-05-24 |
| 2024-05-02 | 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. F0761 · Pharmacy Service Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-05-24 |
| 2024-05-02 | Implement a program that monitors antibiotic use. F0881 · Infection Control Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-05-24 |
| 2024-05-02 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-05-24 |
| 2024-05-02 | Respond appropriately to all alleged violations. F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-05-24 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
9 penalties in the last three years, including $153,657 in fines.
| Date | Type | Amount |
|---|---|---|
| 2025-05-05 | Payment Denial | 21 days payment denial |
| 2025-05-05 | Fine | $58,354 |
| 2025-03-28 | Fine | $34,356 |
| 2024-10-21 | Payment Denial | 8 days payment denial |
| 2024-10-21 | Fine | $12,048 |
| 2024-09-12 | Fine | $15,642 |
| 2023-12-04 | Payment Denial | 48 days payment denial |
| 2023-12-04 | Fine | $18,018 |
| 2023-12-04 | Fine | $15,239 |
Ownership & management
| Name | Role | Since |
|---|---|---|
| PC WCM Opco Holdco LLC (organization) | 5%+ Direct Ownership Interest · 100% | |
| PC WCM Topco LLC (organization) | 5%+ Indirect Ownership Interest | |
| Peace Capital Holdings II LLC (organization) | 5%+ Indirect Ownership Interest | |
| SMS 2021 Trust (organization) | 5%+ Indirect Ownership Interest | |
| Choles, Diana (individual) | Administrator · NOT APPLICABLE | |
| Des Capital LLC (organization) | Administrator · NOT APPLICABLE | |
| JRK Investments LLC (organization) | Administrator · NOT APPLICABLE | |
| Klugman, Jacob (individual) | Administrator · NOT APPLICABLE | |
| Leverentz, Luanne (individual) | Administrator · NOT APPLICABLE | |
| Maina, Jennifer (individual) | Administrator · NOT APPLICABLE | |
| Murphy, Sean (individual) | Administrator · NOT APPLICABLE | |
| PC WCM Propco Holdco LLC (organization) | Administrator · NOT APPLICABLE | |
| PC WCM Topco LLC (organization) | Administrator · NOT APPLICABLE | |
| Peace Capital Holdings II LLC (organization) | Administrator · NOT APPLICABLE | |
| SMS 2021 Trust (organization) | Administrator · NOT APPLICABLE | |
| Stein, Shalom (individual) | Administrator · NOT APPLICABLE | |
| Sternbuch, Daniel (individual) | Administrator · NOT APPLICABLE | |
| Stein, Shalom (individual) | Corporate Officer · NOT APPLICABLE | |
| Klugman, Jacob (individual) | Indirect Ownership Interest · NOT APPLICABLE | |
| Stein, Shalom (individual) | Indirect Ownership Interest · NOT APPLICABLE | |
| Hellman, Yosef (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Stein, Shalom (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Choles, Diana (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Hellman, Yosef (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Maina, Jennifer (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Murphy, Sean (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Sternbuch, Daniel (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Stein, Shalom (individual) | Trustee Of The Snf · NOT APPLICABLE |
Frequently asked questions
What is the rating of Complete Care at Maple Grove LLC?
Complete Care at Maple Grove LLC has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.0-star average in Wisconsin.
How many beds does Complete Care at Maple Grove LLC have?
It has 184 certified beds and cares for about 110 residents per day.
Has Complete Care at Maple Grove LLC been fined?
Yes. CMS lists 9 penalties totaling $153,657 in the last three years.
Who owns Complete Care at Maple Grove LLC?
It is part of Complete Care and is classified as for profit - corporation. See the ownership table above for all owners and managers reported to CMS.
What is the phone number of Complete Care at Maple Grove LLC?
(608) 845-1000. The facility is located at 3401 Maple Grove Dr., Madison, WI 53719.
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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.