Lake Mills Health Services
901 Mulberry St, Lake Mills, WI 53551
Lake Mills Health Services is a nursing home in Lake Mills, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionAugust 3, 2026 (3 months ago)
- Health citations since October 10, 202320 (Wisconsin average 28)
- Fines in the past three years1, $120,900 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 4 of 5.
Health inspection on August 3, 2026
7 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
63 of 323 Wisconsin homes (20%) got a citation at the actual harm level in 2026.
Show the 7 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on August 4, 2026.
CMS has cited this home for F0686 2 times since 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 27, 2026.
CMS has cited this home for F0689 2 times since 2025.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on August 27, 2026.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 25, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on August 26, 2026.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 25, 2026.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on August 24, 2026.
Fire safety inspection on August 3, 2026
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on August 26, 2026.
Citation E0030. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on August 26, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 26, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 16, 2026.
CMS has cited this home for K0918 2 times since 2025.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on August 26, 2026.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 26, 2026.
CMS has cited this home for K0324 2 times since 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 16, 2026.
CMS has cited this home for K0363 3 times since 2024.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on July 3, 2025
4 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $120,900 on July 3, 2025.
Show the 4 citations
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 29, 2025.
Citation F0949. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on July 29, 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on July 29, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 29, 2025.
CMS update of June 25, 2025
Health citation
CMS removed citation F0758 from the health inspection on February 8, 2024.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on March 26, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 14, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 14, 2025.
CMS has cited this home for F0880 2 times since 2023.
Citation F0851. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on April 14, 2025.
Fire safety inspection on March 26, 2025
11 citationsCMS lists this as a standard inspection.
Show the 11 citations
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on April 10, 2025.
CMS has cited this home for E0013 2 times since 2024.
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on April 10, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 31, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on April 15, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 16, 2025.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on April 15, 2025.
Citation K0347. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on August 1, 2025.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 14, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 9, 2025.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on April 16, 2025.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on April 9, 2025.
CMS has cited this home for K0753 2 times since 2024.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of August 29, 2024
Fine
CMS changed the fine from March 22, 2022 from $20,117 to $20,567.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of June 26, 2024
Fine
CMS changed the fine from March 22, 2022 from $19,058 to $20,117.
CMS update of March 28, 2024
Fine
CMS changed the fine from March 22, 2022 from $29,320 to $19,058.
Fine
CMS changed the fine from October 17, 2022 from $80,600 to $52,390.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on February 8, 2024
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0882. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on March 8, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 8, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on March 8, 2024.
Fire safety inspection on February 8, 2024
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on March 21, 2024.
Citation K0131. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for sections of health care facilities separated by fire resistive construction.
CMS lists it as corrected on March 21, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 21, 2024.
Citation K0753. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on March 21, 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on March 21, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 26, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on March 21, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on March 21, 2024.
Citation K0362. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on March 21, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on October 10, 2023
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0563. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
CMS lists it as corrected on November 9, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 9, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 9, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 648-8344
- Last standard health inspection
- August 3, 2026 (3 months ago)
- Certified beds
- 50
- Residents per day, on average
- 28.1
- Ownership type
- For profit - Corporation
- Legal business name
- Nsh Lake Mills LLC
- Chain
- North Shore Healthcare
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (20 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- NSHF OPERATIONS LLC5% or greater direct ownership interest · 100% · since 07/24/2017
- MILLS, DAVID5% or greater indirect ownership interest · 20% · since 06/29/2017
- CIBC BANK USAOperational/managerial control · not applicable · since 12/31/2024
- CLIFTONLARSONALLENOperational/managerial control · not applicable · since 05/22/2018
- CONTINUUM THERAPY PARTNERS LLCOperational/managerial control · not applicable · since 03/01/2025
Show 12 more
- NORTH SHORE HEALTHCARE LLCOperational/managerial control · not applicable · since 10/01/2017
- NSH REHAB LLCOperational/managerial control · not applicable · since 03/01/2025
- WIPFLI LLPOperational/managerial control · not applicable · since 02/01/2025
- BAUMANN, TROYOperational/managerial control · not applicable · since 10/01/2017
- BELONGIA, CHRISTINAOperational/managerial control · not applicable · since 11/01/2019
- GEE, DARRENOperational/managerial control · not applicable · since 11/30/2021
- GREER, LAURENOperational/managerial control · not applicable · since 11/29/2023
- HAMM, CARAOperational/managerial control · not applicable · since 05/04/2026
- HOEHN, JEFFREYOperational/managerial control · not applicable · since 10/01/2017
- PATZER, COLLEENOperational/managerial control · not applicable · since 02/14/2023
- PURTELL, BRIANOperational/managerial control · not applicable · since 06/18/2018
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 02/01/2023
Questions
When was Lake Mills Health Services last inspected?
CMS lists August 3, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Lake Mills Health Services have?
CMS lists 20 health citations since October 10, 2023. CMS also calls these deficiencies.
Has Lake Mills Health Services been fined?
CMS lists 1 fine in the past three years, $120,900 in total.
What is the CMS star rating of Lake Mills Health Services?
Its CMS overall star rating is 2 of 5.
Is Lake Mills Health Services a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.