C-
59/100Lake Mills Health Services Inspection Report, Violations & Safety Grade (LAKE MILLS, Wisconsin)
901 MULBERRY ST, LAKE MILLS, Wisconsin 53551
Phone: 9206488344
CMS Overall:2/5
Overview & Bed Count
Certified Beds
50
Avg Residents/Day
28.1
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Jefferson
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing4/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.58 | 0.98 | +0.60 |
| Total Nurse Hours per Resident per Day | 3.68 | 4.25 | -0.56 |
| CMS Staffing Rating | 4/5 | 3.7/5 | - |
| Nursing Staff Turnover | 33.3% | 46.7% | - |
Health Citation History
20 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-03 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2026-08-03 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-08-03 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2026-08-03 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-08-03 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2026-08-03 | Administration Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-08-03 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2025-07-03 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | J – Immediate Jeopardy |
| 2025-07-03 | Administration Deficiencies | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F – Moderate Harm Potential |
| 2025-07-03 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2025-07-03 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-03-26 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-03-26 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-03-26 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | C – Minimal Harm Potential |
| 2024-02-08 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | E – Moderate Harm Potential |
| 2024-02-08 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-02-08 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2023-10-10 | Resident Rights Deficiencies | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | D – Moderate Harm Potential |
| 2023-10-10 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2023-10-10 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
27 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-03 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2026-08-03 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | F – Moderate Harm Potential |
| 2026-08-03 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-08-03 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-08-03 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2026-08-03 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2026-08-03 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-03-26 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | F – Moderate Harm Potential |
| 2025-03-26 | Emergency Preparedness Deficiencies | Provide emergency officials' contact information. | F – Moderate Harm Potential |
| 2025-03-26 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-03-26 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2025-03-26 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-03-26 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2025-03-26 | Smoke Deficiencies | Properly provide smoke detection systems in areas open to corridors. | E – Moderate Harm Potential |
| 2025-03-26 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-03-26 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-03-26 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | D – Moderate Harm Potential |
| 2025-03-26 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | D – Moderate Harm Potential |
| 2024-02-08 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | F – Moderate Harm Potential |
| 2024-02-08 | Construction Deficiencies | Meet requirements for sections of health care facilities separated by fire resistive construction. | F – Moderate Harm Potential |
| 2024-02-08 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-02-08 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | F – Moderate Harm Potential |
| 2024-02-08 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2024-02-08 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-02-08 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-02-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2024-02-08 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | D – Moderate Harm Potential |
Total Penalties & Fines
$120,900
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-07-03 | Fine | $120,900 | - |
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the LAKE MILLS area at no cost.
Find Safe, Vetted Facilities Near LAKE MILLS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.