Lake Mills Health Services

Name: Lake Mills Health Services
Address: 901 MULBERRY ST, Lake Mills, WI, 53551, US
Telephone: 9206488344

901 Mulberry St, Lake Mills, WI 53551 · Jefferson County · 50 certified beds · avg 28 residents/day · certified since Jul 14, 1981

Part of chain: NORTH SHORE HEALTHCARE (59 facilities, chain avg rating 2.7★)

4/5

Health inspection rating (on-site)

Serious findings on record

$120,900

Fines, last 3 years

4.12

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jul 3, 2025 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 29, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (18)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jul 3, 2025	▲ J · Immediate jeopardy, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jul 3, 2025	F · Potential for harm, facility-wide	The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint
Jul 3, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Jul 3, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 26, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 26, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 26, 2025	C · Minimal risk, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Feb 8, 2024	E · Potential for harm, repeated	The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Feb 8, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Feb 8, 2024	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Oct 10, 2023	D · Potential for harm, one-off	The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint
Oct 10, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Oct 10, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Oct 17, 2022	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Oct 17, 2022	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Oct 17, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 17, 2022	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Oct 17, 2022	C · Minimal risk, facility-wide	The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (3 → 3).

Year	Citations	Serious (G–L)	Worst severity that year
2022	5	0	D
2023	3	0	D
2024	3	0	E
2025	7	1	J ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $120,900.

Date	Type	Amount / length
Jul 3, 2025	Fine	$120,900

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Wisconsin avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.12	4.29	3.95	top 49% in Wisconsin; top 35% in the U.S.
Registered Nurse hours	1.77	1.01	0.69	top 5% in Wisconsin; top 3% in the U.S.
Weekend total nurse staffing	3.86	3.84	3.50	top 42% in Wisconsin; top 27% in the U.S.
Weekend RN hours (not acuity-adjusted)	1.35	0.68	0.48	top 3% in Wisconsin; top 2% in the U.S.
Total nursing staff turnover (%)	37.9	46.9	45.8	top 27% in Wisconsin; top 31% in the U.S.
RN turnover (%)	30.8	39.7	42.9	top 38% in Wisconsin; top 30% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.54, RN 1.52, weekend 3.32. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Mills, David	Individual	5% or Greater Indirect Ownership Interest	20%	06/29/2017
NSHF Operations LLC	Organization	5% or Greater Direct Ownership Interest	100%	07/24/2017
Baumann, Troy	Individual	W-2 Managing Employee	NOT APPLICABLE	06/29/2017
Baumann, Troy	Individual	Corporate Director	NOT APPLICABLE	06/29/2017
Hoehn, Jeffrey	Individual	Corporate Director	NOT APPLICABLE	06/29/2017
North Shore Healthcare LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	10/01/2017

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"What training do your staff receive for caring for residents with dementia or mental health conditions?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
"Who is your infection preventionist, and what training do they have?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Alden Estates of Countryside, INC	7.5 mi	Jefferson, WI	★☆☆☆☆	1/5
Rock River Nursing & Rehab	11.1 mi	Fort Atkinson, WI	★☆☆☆☆	1/5
Marquardt Memorial Manor	12.7 mi	Watertown, WI	★★☆☆☆	2/5
Watertown Health Care Center	12.9 mi	Watertown, WI	★☆☆☆☆	1/5	SFF
Sun Prairie Senior Living	17.2 mi	Sun Prairie, WI	★★★☆☆	3/5
Avina of Sun Prairie	18.2 mi	Sun Prairie, WI	★★★★★	4/5
Columbus Health and Rehab	18.4 mi	Columbus, WI	★★☆☆☆	2/5
Oak Park Nursing and Rehab Center	19.2 mi	Madison, WI	★☆☆☆☆	1/5
Skaalen Nursing and Rehabilitation Center	19.2 mi	Stoughton, WI	★★★★★	5/5
Edgerton Care Center, INC	19.2 mi	Edgerton, WI	★☆☆☆☆	1/5	abuse
Shorehaven HLTH & Rehab Ctr	19.4 mi	Oconomowoc, WI	★★★★★	4/5
Oakwood Village East Health and Rehab Center	19.9 mi	Madison, WI	★★★☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Lake Mills →

Facility data as of CMS processing date 2026-08-01. CCN 525314.

The Care File

Visit checklist — Lake Mills Health Services

901 Mulberry St, Lake Mills, WI 53551 · 9206488344

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $120,900

Most serious findings on record:

▲ Jul 3, 2025 (F-0686, Immediate jeopardy, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Questions for the administrator:

☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "What training do your staff receive for caring for residents with dementia or mental health conditions?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
☐ "Who is your infection preventionist, and what training do they have?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 525314 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)