Lake Mills Health Services
901 Mulberry St, Lake Mills, WI 53551 · For profit - Corporation · 50 certified beds · (920) 648-8344 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $120,900 in federal fines (most recent 2025-07-03)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.9% | 16.1% | 15.4% | typical |
| Long-stay residents who lose too much weight | 10.0% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.7% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.4% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 15.7% | 18.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 31.5% | 16.9% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 9.1% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.6% | 24.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.0% | 15.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 76.0% | 82.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.7% | 23.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.8% | 15.5% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.3%CMS range 44.7–72.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.5–15.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.6–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 28.3 residents a day — about 57% occupied, or roughly 22 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.52 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.63 on weekdays — 9% thinner on weekends. RN hours go from 1.59 to 1.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-07-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R1 andR4) of 3 residents reviewed for pressure injuries. * R1 admitted to the facility on [DATE] with a hospital discharge summary that included treatment for R1’s right ischium. This treatment was not picked up by the facility. On 5/14/25, the facility documented a stage 2 pressure injury (PI) to R1’s right buttock. Wound Physician-G’s treatment recommendation for the right buttock was not completed by the facility. On 5/27/25, the right buttock PI was noted to have declined, and Wound Physician-G changed the treatment orders. These orders were not picked up by the facility, and the facility did not develop a PI care plan for R1. The facility also failed to implement physician’s treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-03 · tag F0949 — failed to train staff on dementia and abuse — widespreadProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility did not ensure 7 out of 8 staff members reviewed received behavioral health training to care for residents diagnosed with a mental, psychosocial, or other behavioral health conditions. Certified Nursing Assistant (CNA)-Q, CNA-R, CNA-T, CNA-V, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z, did not receive behavioral health training.This deficient practice has the potential to affect all 29 residents residing at the facility that have the potential to experience behavioral health issues. Findings include:On 7/3/25, Surveyor randomly selected 8 facility staff members for review. Surveyor reviewed the employee records of CNA-Q, CNA-R, CNA-T, CNA-V, CNA-X, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z. The facility was unable to provide documentation that CNA-Q, CNA-R, CNA-T, CNA-V, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z, received the required behavioral health training within the year based on hire date.CNA-Q Date of Hire: 1/1/23 (did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the facility that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider or a discharge summary that includes a recapitulation of the resident's stay to ensure a safe and orderly discharge for 2 (R2, R4) or 2 residents.* R2 has no documented discharge summary included recapitulation of R2's stay in the facility in R2's medical record. There was not documentation that R2 was explained or educated on medications, follow up appointments, self-catheterization or therapies that R2 was to receive after discharge home. * R1 had no discharge documentation, including a recapitulation of R1's stay, sent with R1 when R1 was discharged on 6/11 to an assisted living facility until R1 was already discharged from the facility and residing at the assisted living facility.Findings include:The facility's policy titled, Transfer and discharge:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure residents with non pressure wounds received treatment and care in accordance with professional standards of practice for 1 (R1) of 1 residents reviewed with a non-pressure wound.R1 was admitted with a right lower extremity wound on 5/14/25. On 5/21/25, R1's wound treatment was changed. The facility did not recognize the scheduled treatment, only the PRN (as needed) portion of the order was implemented. R1 was not provided with treatment to the right lower extremity wound from 5/21/25 to 5/27/25 when the wound was identified as being healed.Findings include:The facility's policy titled, Pressure Injuries and Non Pressure Injuries and reviewed/revised 7/20/22 under policy documents: For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility did not ensure 1 (R23) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. R23 had a guided assist to the floor when being transferred with a gait belt and 1 staff member assist. R23 was assessed and the care plan documented R23 required a gait belt and 2 staff members assist with transfers. Findings include: The facility policy titled Fall Prevention and Management Guidelines revised on 7/18/2024 documents: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. Policy Explanation and Compliance Guidelines: . 4. Suggested standard interventions may include: . c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. R23 was admitted to the facility on [DATE] and has diagnoses that include transient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R7 and R23) of 6 residents reviewed. Registered Nurse Unit Manager (RN UM)-H and RN-G did not wear appropriate personal protective equipment (PPE) during a treatment observation for R7. RN UM-H and RN-G were not aware of where PPE is kept for residents requiring enhanced barrier precautions. There was not an enhanced barrier precaution (EBP) sign on R23's door consistent with other residents identified as requiring EBP. Registered Nurse (RN)-I did not wear appropriate personal protective equipment (PPE) during a treatment observation for R23. R23 has a stage 4 pressure injury to the left outer ankle requiring a dressing and did have light serous drainage on 3/25/2025. Findings include: The facility policy titled Enhanced Barrier Precaution reviewed/revised on 8/8/2024 documents: It is the policy of this facility to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-08 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility did not have a qualified Infection Preventionist who worked at least part time which had the potential to affect all 24 residents residing in the facility. *The Director of Nursing (DON)-B was serving as the facility's Infection Preventionist and did not have proper credentials. Findings include: On 02/08/24 08:53 AM, Surveyor interviewed DON (Director of Nursing)-B. DON-B informed Surveyor she had overseen infection control since August. Per DON-B, Nursing Home Administrator (NHA)-A assists with Infection Control if the facility has a Covid outbreak. DON-B informed Surveyor she had not completed an infection control certification training program. Per DON-B she had started the CDC (Center for Disease Control) modules but had never completed them. DON-B stated she does plan on completing the training and taking the test. On 02/08/24 at 9:30 AM, Surveyor interviewed NHA-A. NHA-A informed Surveyor he kept track of all the Covid testing and line lists during the facility's Covid outbreak in November. Per NHA-A, he is not Infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the Facility did not ensure 1 (R11) of 5 residents were free from unnecessary medications. *R11 was prescribed Seroquel (Quetiapine) without adequate diagnoses, quantitative behavior monitoring and a lack of a timely Abnormal Involuntary Movement Scale (AIMs) assessment. Findings include: Facility policy entitled, Psychotropic Medications, revised on 10/24/22 documented: Residents should not received psychotropic drugs unless the medication is necessary to treat specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrator by monitoring and documentation of the resident's response to the medication .The indications for use of any psychotropic drug will be documented in the medical record .Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation .Residents who receive an antipsychotic medication will have an AIMs test…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the Facility did not ensure 1 (R6) of 1 residents reviewed were free from significant medication errors. *R6 had an order for Apixaban that was transcribed incorrectly. As a result, R6 only received one dose of Apixaban instead of two from 10/31/23 to 11/27/23. Findings include: R6 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Hypertension and Atrial Fibrillation (AFIB) on Chronic Anticoagulation. Surveyor reviewed R6's Electronic Health Record (EHR) and noted the following active physician's order: Apixaban 2.5 mg (milligrams), one tablet twice a day, with a start date of 11/27/23. Surveyor noted the following discontinued physician's order in R6's EHR: Apixaban 2.5mg, one tablet at HS (hour of sleep). This order had a start date of 10/31/23 and a discontinued date of 11/27/23. Surveyor reviewed R6's progress notes and noted the following documentation: On 10/31/2023 a Pharmacy Review stated: Late Entry: (11/01/23)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0563 — failed to protect the right to visitors — isolatedHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and family interview, and record review, the facility did not ensure 2 Residents (R) (R5 and R1) of 10 residents on the COVID-19 unit were allowed to receive visitors. R5 indicated the facility did not allow visitors on the COVID-19 unit during an outbreak in February of 2023. R1's family was not allowed to visit on the COVID-19 unit during an outbreak in February of 2023. Findings include: The facility's COVID-19: Visitation & Communal Activities/Dining policy, last revised on 10/4/22, indicated: This facility encourages residents to exercise their right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident .The core principles of COVID-19 infection prevention will be adhered to and as follows: .d. Visitors should be informed about their potential to be exposed to COVID-19 infection in the facility. e. Hand hygiene, using an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure timely administration of medication for 1 Resident (R) (R1) of 8 sampled residents. R1 did not consistently receive R1's scheduled morphine (used to treat moderate to severe pain) timely. Findings include: The facility's Medication Administration policy, dated 1/2023, indicated: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the Prescriber, routine medications are administered according to the established medication administration schedule for the nursing center . On 10/9/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra (bone in spinal column). R1's Minimum Data Set (MDS) assessment, dated 2/13/23, contained a Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · Dcited before2023-10-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene during the provision of cares for 1 Resident (R) (R4) of 2 residents. On 10/10/23, Certified Nursing Assistant (CNA)-C did not consistently perform hand hygiene during the provision of perineal care for R4. In addition, Director of Nursing (DON)-B did not consistently perform hand hygiene during the provision of wound care for R4. Findings include: The facility's Hand Hygiene policy, with a revision date of 11/2/22, indicated: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .6. a. The use of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-17 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility did not provide an ongoing program to support Residents in their choice of activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all 2 (R19 and R10) of 4 Resident who attended the Quality of Life Assessment Group interview on 10/11/22 at 10:04 AM. * R19 and R10 confirmed that activities have not been occurring per the posted activity calendar and that their activities of choice have not been met while residing at the facility. Findings Include: Surveyor reviewed the facility Activity Program policy and procedure effective 6/1/17 and notes the following applicable: Purpose * Provide a wide range of activities to enhance the lives of Residents * Provide opportunities for Residents and staff to interact on a social basis. Procedure 1. Activities will be scheduled on a regular basis to enrich the lives of Residents. *Scheduled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that a resident with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 2 (R277) residents reviewed for pressure injuries. *On 10/4/2022, R277 was admitted to the facility with a stage III pressure injury on their heel and the facility did not initiate the appropriate pressure reducing mattress. Findings Include: The Facility Policy and Procedure, entitled Pressure and Non-pressure Injuries, dated 8/2/21, documents (in part) . Policy This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with .a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that 1 (R21) of 4 Residents reviewed who were at risk for falls received the necessary services/interventions and supervision to prevent an injury from a fall. Findings Include: Surveyor reviewed the facility's Fall Prevention and Management Guidelines policy and procedure effective 2/2017 and notes the following: Policy The facility will maintain a fall prevention and management program. The elderly are at increased risk for falls related to several different factors. The facility will implement a fall program for Residents determined to be a risk for falls in order to better manage these factors and prevent and/or manage as much as is possible the Resident from falling and/or sustaining injuries related to falling. Procedure Fall Prevention and Management Guidelines Objectives: - Appropriate fall management may result in reducing falls, minimizing injuries, and ultimately improving the quality of life of Residents - Limit or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the necessary care and services to provide respiratory care for 3 (R277, R21 and R128, ) of 4 residents reviewed receiving oxygen care. *R277 was observed during survey with and without oxygen on. R277's medical record did not include a physician's order for oxygen and oxygen was not included on R277's baseline care plan. *R21's medical record included an order for oxygen. R21 was observed during survey without the oxygen on. R21's oxygen tubing and humidifier was not changed per facility policy. R21's care plan did not include oxygen usage. *R128 was observed during survey wearing oxygen. The oxygen humidifier and oxygen tubing was not dated. R128 has a physician order to change oxygen tubing and humidifier bottles weekly and to date tubing one time every Monday. R128's care plan did not include oxygen usage. Findings Include: The Facility Policy and Procedure, entitled Oxygen Administration, dated 6/2017, documents (in part) .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-03-26 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the fourth quarter of 2024 (July 1st-September), was accurate. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for low weekend staffing. This had the potential to affect all 27 residents. Findings include: Review of the facility PBJ data, as part of the survey offsite process, indicates during the fourth quarter of the federal fiscal year 2024 (July 1st - September 30th) the facility was triggered for excessively low weekend staffing. Surveyor did conduct a review of the daily staff schedules from July 1, 2024, to September 30, 2024. Surveyor noted both licensed nurses and certified nursing assistants present on each shift and for each unit. When call-ins happened, it was indicated on the schedule and it also was documented who placed the call-in, if applicable. On 03/25/25, at 03:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A and [NAME] President of Success (VP of Success)- C regarding the PB& J…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2022-10-17 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, and the Quality of Life Assessment Group interview, the facility did not always provide orally and in writing, in a language that Residents can understand the notice of rights, rules, regulations and services prior to or upon admission and the facility did not post the full list of Resident rights within the facility for all 33 Residents currently residing in the facility. Findings Include: Surveyor reviewed the facility's Resident Rights policy and procedure effective 9/26/2017 and notes the following: Purpose *To ensure that Resident rights are respected, protected, and promoted *To inform Residents of their rights and provide an environment in which they can be exercised Procedure Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. This facility will treat each Resident with respect and dignity and care for each Resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each Resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$120,900 in federal fines across 1 penalty.
- $120,900 — penalty dated 2025-07-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.7 | +1.3 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 3 of 5 | 2.5 | +0.5 vs chain |
The other 58 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 58; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NSHF OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/24/2017 |
| MILLS, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 06/29/2017 |
| BAUMANN, TROY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 06/29/2017 |
| HOEHN, JEFFREY | Individual | CORPORATE DIRECTOR | — | since 06/29/2017 |
| NORTH SHORE HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2017 |
CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $170K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wisconsin Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 525314. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.