Lancaster Health Services
1350 S Madison St, Lancaster, WI 53813 · Grant County · 50 certified beds · avg 42 residents/day · certified since Mar 1, 1984
Part of chain: NORTH SHORE HEALTHCARE (59 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Aug 19, 2025 · F-0605
The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Why it matters: Using sedating drugs as a 'chemical restraint' can rob residents of alertness and mobility and increases risks of falls and death, especially in people with dementia.
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: Sep 16, 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 |
|---|---|---|
| Aug 19, 2025 | ▲ J · Immediate jeopardy, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 19, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 19, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 19, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 19, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 19, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 19, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Feb 19, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 19, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 27, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Jul 24, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jul 24, 2024 | 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. |
| Apr 24, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 6, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 6, 2023 | F · Potential for harm, facility-wide | 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. |
| Apr 6, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 6, 2023 | C · Minimal risk, facility-wide | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | F |
| 2024 | 5 | 0 | F |
| 2025 | 9 | 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)
No fines or payment denials in the published 3-year window.
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) | 3.57 | 4.29 | 3.95 | bottom 28% in Wisconsin; bottom 40% in the U.S. |
| Registered Nurse hours | 0.67 | 1.01 | 0.69 | bottom 19% in Wisconsin; top 39% in the U.S. |
| Weekend total nurse staffing | 3.23 | 3.84 | 3.50 | bottom 30% in Wisconsin; bottom 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.68 | 0.48 | bottom 12% in Wisconsin; bottom 46% in the U.S. |
| Total nursing staff turnover (%) | 28.0 | 46.9 | 45.8 | top 9% in Wisconsin; top 11% in the U.S. |
| RN turnover (%) | 28.6 | 39.7 | 42.9 | top 34% in Wisconsin; top 26% 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 3.62, RN 0.69, weekend 3.29. 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: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Arrowhead 123 LLC | Organization | 5% or Greater Indirect Ownership Interest | 10% | 10/01/2019 |
| Mills, David | Individual | 5% or Greater Indirect Ownership Interest | 18% | 10/01/2019 |
| NSHR Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 10/01/2019 |
| The Lane Morrell Bowen Trust | Organization | 5% or Greater Indirect Ownership Interest | 10% | 10/01/2019 |
| Arrowhead 123 LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Baumann, Troy | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Baumann, Troy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Baumann, Troy | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Belongia, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Belongia, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2019 |
| Cibc Bank USA | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/31/2024 |
| Cibc Bank USA | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 12/31/2024 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/31/2024 |
| Cliftonlarsonallen LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2019 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 06/06/2025 |
| Continuum Therapy Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Continuum Therapy Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/06/2025 |
| Gee, Darren | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/30/2021 |
| Gee, Darren | Individual | ADP of the SNF | NOT APPLICABLE | 11/30/2021 |
| Greer, Lauren | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/29/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "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 |
|---|---|---|---|---|---|
| Orchard Manor | 1.4 mi | Lancaster, WI | ★★★★★ | 5/5 | |
| Dove Healthcare - Fennimore | 10.3 mi | Fennimore, WI | ★★☆☆☆ | 2/5 | |
| Edenbrook of Platteville | 13.8 mi | Platteville, WI | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525352.