Williams Bay Health Services
146 Clover St, Williams Bay, WI 53191
Williams Bay Health Services is a nursing home in Williams Bay, 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.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (262) 245-6400
- Last standard health inspection
- June 3, 2026 (5 months ago)
- Certified beds
- 50
- Residents per day, on average
- 33.3
- Ownership type
- For profit - Corporation
- Legal business name
- Nsh Williams Bay LLC
- Chain
- North Shore Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (32 vs 28).
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 quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
27 citations
Health inspection on June 3, 2026
CMS lists this as a standard inspection and 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.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
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 7, 2026.
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 July 7, 2026.
CMS has cited this home for F0689 3 times since 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 7, 2026.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on July 7, 2026.
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 7, 2026.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 7, 2026.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on July 7, 2026.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 7, 2026.
CMS has cited this home for F0880 2 times since 2025.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on July 7, 2026.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 7, 2026.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on July 7, 2026.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on July 7, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 7, 2026.
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 7, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 7, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 7, 2026.
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 7, 2026.
Citation F0691. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on July 7, 2026.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on July 7, 2026.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on July 7, 2026.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on July 7, 2026.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 7, 2026.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on July 7, 2026.
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 July 7, 2026.
Citation F0944. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on July 7, 2026.
Citation F0947. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on July 7, 2026.
Citation F0575. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
CMS lists it as corrected on July 7, 2026.
8 citations
Fire safety inspection on June 3, 2026
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on July 2, 2026.
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 July 2, 2026.
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 July 2, 2026.
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 July 2, 2026.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for K0341 2 times since 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on July 2, 2026.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 2, 2026.
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 July 2, 2026.
CMS has cited this home for K0353 3 times since 2024.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on January 26, 2026
CMS lists this as a complaint inspection.
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 February 23, 2026.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 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 2 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 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 3 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 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5.
4 citations
Health inspection on March 27, 2025
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 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 April 24, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 24, 2025.
Citation F0909. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
CMS lists it as corrected on April 24, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 24, 2025.
8 citations
Fire safety inspection on March 27, 2025
CMS lists this as a standard inspection.
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 24, 2025.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on April 22, 2025.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on April 24, 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 24, 2025.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 24, 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 24, 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 24, 2025.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 24, 2025.
CMS has cited this home for K0712 2 times since 2024.
CMS update of October 30, 2024
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 1 of 5 to 2 of 5.
CMS update of August 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 2 of 5 to 3 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of January 31, 2024
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 2 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from July 20, 2022 from $90,600 to $58,890.
8 citations
Fire safety inspection on January 25, 2024
CMS lists this as a standard inspection.
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 February 21, 2024.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on February 21, 2024.
Citation K0342. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on February 21, 2024.
Citation K0343. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
CMS lists it as corrected on February 21, 2024.
Citation K0912. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on February 21, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 21, 2024.
Citation K0341. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on February 21, 2024.
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 February 21, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- NSHR OPERATIONS LLC5% or greater direct ownership interest · 100% · since 10/01/2019
- ARROWHEAD 123 LLC5% or greater indirect ownership interest · 10% · since 10/01/2019
- THE LANE MORRELL BOWEN TRUST5% or greater indirect ownership interest · 10% · since 10/01/2019
- MILLS, DAVID5% or greater indirect ownership interest · 18% · since 10/01/2019
- CIBC BANK USAOperational/managerial control · not applicable · since 12/31/2024
- CLIFTONLARSONALLENOperational/managerial control · not applicable · since 12/01/2019
- CONTINUUM THERAPY PARTNERS LLCOperational/managerial control · not applicable · since 03/01/2025
- NORTH SHORE HEALTHCARE LLCOperational/managerial control · not applicable · since 12/01/2019
- 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 12/01/2019
- BELONGIA, CHRISTINAOperational/managerial control · not applicable · since 12/01/2019
- GEE, DARRENOperational/managerial control · not applicable · since 11/30/2021
- GREER, LAURENOperational/managerial control · not applicable · since 11/29/2023
- HOEHN, JEFFREYOperational/managerial control · not applicable · since 12/01/2019
- JACOBSON, GAILOperational/managerial control · not applicable · since 07/20/2026
- PATZER, COLLEENOperational/managerial control · not applicable · since 02/14/2023
- PURTELL, BRIANOperational/managerial control · not applicable · since 12/01/2019
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 01/01/2023
Questions
When was Williams Bay Health Services last inspected?
CMS lists June 3, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Williams Bay Health Services have?
CMS lists 32 health citations since March 27, 2025. CMS also calls these deficiencies.
Has Williams Bay Health Services been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Williams Bay Health Services?
Its CMS overall star rating is 1 of 5.
Is Williams Bay Health Services a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.