D
Complete Care at Maple Grove LLC
42/100 score
1.16 hrs RN staffing
17 deficiencies
Oak Park Place of Nakoma
4327 Nakoma Rd., Madison, WI 53711
B
At or above the 2024 benchmark — above average inspection record.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
1.82 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
30
Outstanding
0
Actual harm or worse (G–L)
0
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★☆ (4/5)
Staffing: ★★★★☆ (4/5)
|
|
NursingHomeGrade Score
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70/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
30 deficiencies found. 30 corrected. None involved actual harm.
Most recent inspection (January 22, 2026)
F
Potential harm — widespread
F0868
Status: Corrected
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2026
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2026
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2026
F
Potential harm — widespread
F0814
Status: Corrected
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2026
D
Potential harm — isolated
F0692
Status: Corrected
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 19, 2025
E
Potential harm — pattern
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2026
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2026
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 19, 2025
D
Potential harm — isolated
F0627
Status: Corrected
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026
D
Potential harm — isolated
F0554
Status: Corrected
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2026
C
No harm — widespread
F0582
Status: Corrected
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2026
Inspection cycle 2 (January 15, 2025)
D
Potential harm — isolated
F0610
Status: Corrected
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 15, 2025
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
D
Potential harm — isolated
F0883
Status: Corrected
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
D
Potential harm — isolated
F0887
Status: Corrected
Educate 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 Control Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
D
Potential harm — isolated
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 15, 2025
D
Potential harm — isolated
F0757
Status: Corrected
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
E
Potential harm — pattern
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
D
Potential harm — isolated
F0695
Status: Corrected
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
E
Potential harm — pattern
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 15, 2025
D
Potential harm — isolated
F0623
Status: Corrected
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
D
Potential harm — isolated
F0625
Status: Corrected
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2024
Inspection cycle 3 (July 20, 2023)
C
No harm — widespread
F0851
Status: Corrected
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
F
Potential harm — widespread
F0868
Status: Corrected
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
D
Potential harm — isolated
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
D
Potential harm — isolated
F0678
Status: Corrected
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
D
Potential harm — isolated
F0585
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 20, 2023
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