Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Mills Care Center during CMS and state inspections, most recent first.
Unhygienic food storage and unsafe feeding practices were observed when food was found open, spoiled-smelling, and contaminated in a refrigerator, and a CMA assisted residents with eating without hand hygiene. The CMA fed two residents while alternating between them without sanitizing hands, touched both ends of a straw before giving it to a resident, and handled a resident’s toast with bare hands before adding condiments. The residents included individuals with dementia and dysphagia who required varying levels of assistance with eating.
A resident with severe cognitive impairment experienced a witnessed fall and subsequently reported severe, uncontrolled pain. Despite repeated requests for help and a documented pain score of 10, the on-duty LPN only administered Tylenol and faxed the physician, delaying further evaluation. The resident continued to express distress until the next shift, when another nurse recognized the severity and sent the resident to the hospital, where a serious fracture was diagnosed. The facility lacked clear policy guidance and staff education on pain assessment and physician notification after falls.
Two residents receiving high-risk medications, including anticoagulants, diuretics, and insulin, did not have comprehensive care plans with appropriate goals and interventions addressing these therapies. One resident with multiple chronic conditions lacked care plan documentation for anticoagulant and diuretic use, while another resident with diabetes had no care plan entries for diabetes or insulin management. The omissions were confirmed through record review and staff interview.
The facility failed to promptly notify a physician and implement appropriate care for a resident with new UTI symptoms, resulting in unresolved pain over several days, and also did not notify a physician in a timely manner for another resident with elevated blood sugar levels. In both cases, staff did not follow facility policy for timely assessment and physician communication, leading to delays in care.
A resident with severe cognitive impairment and multiple risk factors developed a deep tissue pressure injury to the heel despite existing preventive measures. The facility failed to promptly reassess risk and implement additional interventions after a change in condition, delayed obtaining a wound care consult, and did not address the resident's footwear in relation to the ulcer, resulting in care inconsistent with professional standards.
The facility did not post required daily nurse staffing information, omitting the resident census, total hours worked for each staff category, and whether nurses were LPNs or RNs for each shift. Staff interviews confirmed a lack of awareness about these omissions, despite a reported census of 52 residents.
Unhygienic Food Storage and Unsafe Feeding Practices
Penalty
Summary
The facility failed to protect residents from pathogens when food was stored in an unhygienic manner and when staff assisted residents with eating using unsanitary practices. During a kitchen observation, a container of cheese slices was found unsealed and open to the air in the refrigerator, a smell resembling spoiled milk was noted upon entering the refrigerator, and a sticky, smelly substance was observed covering a box of sealed yogurt containers. The facility’s Food Handling policy required employees to perform hand hygiene prior to handling food, prohibited touching ready-to-eat foods with bare hands, and required foods prepared in operation to be covered and labeled before storage. During dining service, a CMA assisted two residents with eating and did not perform hand hygiene before feeding them. The staff member alternated between the two residents and frequently used the same hand to feed both without washing or sanitizing hands between residents or bites. The staff member also unwrapped a straw and touched both drinking ends before giving it to a resident, then later picked up another resident’s toast with ungloved hands and appeared to butter and jelly it before allowing the resident to eat it. The residents involved included one with Alzheimer’s disease, non-Alzheimer’s dementia, and oropharyngeal dysphagia who required substantial to maximal assistance with eating, and another resident with non-Alzheimer’s dementia who required supervision or touch assistance while eating; a third resident had oral phase dysphagia and required supervision or touch assistance while eating.
Failure to Promptly Address and Report Acute Pain Following Resident Fall
Penalty
Summary
The facility failed to promptly identify, intervene, and notify the provider regarding an acute change in a resident's uncontrolled pain following a witnessed fall. After the fall, the resident, who had a history of severe cognitive impairment and other medical conditions, reported significant pain in her leg but was able to move her legs during the initial assessment. Despite the resident expressing that the pain was the worst she had ever experienced and repeatedly using her call light to request help, the nurse on duty only administered Tylenol and faxed the physician, rather than sending the resident for immediate evaluation. Throughout the early morning hours, the resident continued to express severe pain, activating her call light seven times within a 25-minute period. Staff interviews revealed that aides and nurses were aware of the resident's ongoing distress, but the nurse decided not to escalate care or notify the physician directly, citing facility practice and the presence of a different provider. The nurse relied on her discretion and did not recognize the severity of the pain as a significant change from the resident's baseline, despite documentation of a pain score of 10 and staff observations of the resident's distress. It was not until the next shift, when another nurse observed the resident yelling in pain and noted physical signs such as facial grimacing and an abducted leg, that the decision was made to send the resident to the hospital. Hospital records later confirmed a serious injury, specifically a comminuted left acetabular fracture with protrusion of the femoral head. The facility's fall policy lacked clear guidance on pain assessment and physician notification following falls, and the Director of Nursing confirmed that staff had not received education on these procedures.
Failure to Develop Comprehensive Care Plans for Residents on High-Risk Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all the needs of two residents who were prescribed high-risk medications. For one resident with a history of heart failure, hypertension, deep vein thrombosis, and respiratory failure, the care plan did not include goals or interventions related to the use of anticoagulants (apixaban) and diuretics (torsemide and spironolactone), despite these medications being ordered and administered for her conditions. This omission was identified through a review of the resident's Minimum Data Set (MDS), order summary, and current care plan. Additionally, another resident with a diagnosis of diabetes and documented use of insulin was found to have no care plan documentation addressing diabetes management, insulin therapy, or related interventions. The MDS coordinator acknowledged during an interview that the resident's diabetes and insulin use were missed on the care plan. These findings were based on record reviews and staff interviews, and the facility census at the time was 52 residents.
Delayed Physician Notification and Response for Change in Condition
Penalty
Summary
The facility failed to promptly implement and ensure physician notification and response for a resident who exhibited new onset signs and symptoms of a urinary tract infection (UTI). The resident, who had a history of diabetes mellitus, heart failure, and renal failure, began experiencing pain, burning, urgency, and increased incontinence with urination over a weekend. Despite repeatedly informing nursing staff of her symptoms and requesting intervention, the resident did not receive timely assessment or physician notification. Documentation shows that a change in condition assessment was completed, but the physician was not notified until the following Monday, and a urine sample was not collected until the next day. The resident endured unresolved pain and discomfort for several days, and there was a lack of ongoing assessment, including vital signs and pain evaluation, during this period. Additionally, the facility failed to notify a physician in a timely manner for another resident with elevated blood sugar levels. This resident, who had diagnoses including diabetes mellitus and was receiving daily insulin injections, had multiple blood glucose readings significantly above the normal range. There was no documentation of physician notification regarding these elevated levels, despite facility policy requiring such action when blood sugars are outside of parameters. The care plan for this resident also lacked specific blood sugar parameters, and the resident was not assessed or reported to the physician until the following day. Interviews with staff, including the DON, confirmed that the expected protocol was not followed in both cases. The facility's own policies require timely physician notification and thorough documentation when a resident experiences a change in condition or abnormal lab results. However, in both instances, there was a delay in notifying the physician and implementing appropriate interventions, resulting in delayed care for the affected residents.
Failure to Provide Timely Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with severe cognitive impairment, non-Alzheimer's dementia, and Multiple Sclerosis was identified as being at risk for pressure ulcers but initially had no such wounds. The care plan included interventions such as pressure-reducing devices for the bed and chair, a turning and repositioning program, and nutritional support. Despite these measures, the resident developed a dark purple, non-blanchable area on the right heel, later identified as a deep tissue pressure injury. Documentation shows that the resident experienced a change in condition, including lethargy, confusion, and increased care needs, but there was no evidence of repeated risk assessments or additional interventions at the time of this change, as recommended by professional guidelines. After the pressure injury was first documented, there was a significant delay in obtaining a wound care consult. Although the physician and family were involved in discussions about hospice care and wound management, the clinical record lacked documentation of timely attempts to secure a wound care consult or evaluation. Multiple progress notes indicated ongoing communication with the physician and family, but the facility did not document efforts to arrange for wound care services until much later, despite the wound increasing in size and changing in appearance. Additionally, the facility did not address the resident's footwear in relation to the pressure ulcer, even though the resident continued to wear shoes and slippers after the injury developed. Staff acknowledged the lag in wound care intervention and the lack of documentation regarding footwear recommendations. The facility's actions and omissions resulted in a failure to provide care consistent with professional standards to prevent the development of a pressure ulcer and to provide necessary treatment and services to promote healing once the ulcer was present.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the resident census, total hours worked for each staff category, and identification of whether nurses were LPNs or RNs for each shift. Multiple observations over two days revealed that the posted staffing information was missing these required elements. Staff interviews confirmed a lack of awareness regarding the omission of census data and proper identification of nursing staff categories on the postings. The facility reported a census of 52 residents during this period.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lake Mills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Forest City | 16.7 mi | ★★★★★ | 0 | 0 |
| Parkview Care Center | 16.7 mi | ★★★★★ | 12 | 0 |
| Timely Mission Nursing Home | 17 mi | ★★★★★ | 1 | 0 |
| St Johns On Fountain Lake | 17.7 mi | ★★★★★ | 15 | 0 |
| Thorne Crest Retirement Center | 18.5 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.