Cycle 1
Health 2025-03-26 · Fire 2025-03-26
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Lake Mills, WI
Lake Mills Health Services
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
901 Mulberry St, Lake Mills, WI
(920) 648-8344
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1981-07-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.61
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.22
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.27
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.85
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,925
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9950
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.01
Performance 20.04% · Measure score 3.01 · Achievement 3.01 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.65
Performance 7.34% · Measure score 1.65 · Achievement 1.65 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.97
Baseline 66.67% · Performance 31.25% · Measure score 7.97 · Achievement 7.93 · Improvement 7.97
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.33% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 2.5% · Lower 95% interval 6.45% |
| Discharge to community | 57.28% |
50.57%
6.7 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 55% · Lower 95% interval 44.7% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 3.7% |
0.77%
2.9 pts worse
|
Numerator 1 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 7.41% |
2.29%
5.1 pts worse
|
Numerator 2 · Denominator 27 · Adjusted rate 7.49% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 2.13% |
8.2%
6.1 pts worse
|
Numerator 1 · Denominator 47 |
| Staff flu vaccination coverage | 46.51% |
42%
4.5 pts better
|
Numerator 20 · Denominator 43 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
95.7%
0.9 pts worse
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 95.5% · Q4 95.7% · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
5.0%
0.7 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 5.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
4.9%
2.5 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
16.6%
4.8 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.5% |
16.7%
5.8 pts worse
|
16.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.3% |
21.1%
2.2 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
17.3%
6.3 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 2.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
25.5%
5.1 pts better
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 15.8% |
5.5%
10.3 pts worse
|
5.1%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 11.4% · Q4 10.7% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
86.8%
2.4 pts worse
|
81.7%
2.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 82.4% · Q3 92.7% · Q4 87.8% · 4Q avg 84.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
15.0%
3.9 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 12.5% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.0% |
82.2%
6.2 pts worse
|
79.7%
3.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
22.7%
1.5 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.8% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-10-17 · Fire 2022-10-17
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-26
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-03-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-15
F · Potential for more than minimal harm
2025-03-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-26
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-03-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-26
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-04-09
F · Potential for more than minimal harm
2024-02-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-21
F · Potential for more than minimal harm
2024-02-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-08
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-03-21
L · Immediate jeopardy
2022-10-17
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-10-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-10-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-10-17
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-10-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-10-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-11-11
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-29
F · Potential for more than minimal harm
2025-07-03
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-03-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-14
C · Minimal harm
2025-03-26
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-04-14
E · Potential for more than minimal harm
2024-02-08
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-10-10
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-09
D · Potential for more than minimal harm
2022-10-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-11
C · Minimal harm
2022-10-17
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
Ownership
Nshf Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Mills, David
5% Or Greater Indirect Ownership Interest · Individual
Baumann, Troy
Corporate Director · Individual
Baumann, Troy
W-2 Managing Employee · Individual
Hoehn, Jeffrey
Corporate Director · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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1-star overall rating with 1-star inspections with $114,395 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Rock River Nursing & Rehab
Fort Atkinson, WI
0-star overall rating with 0-star inspections with Special Focus status with $136,384 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Marquardt Memorial Manor
Watertown, WI
1-star overall rating with 2-star inspections with $40,480 in total fines with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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