Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health Services during CMS and state inspections, most recent first.
Two residents with or at risk for pressure injuries did not receive necessary treatment and services consistent with professional standards. One resident was admitted with a stage 2 pressure injury and multiple comorbidities, but the facility failed to implement hospital discharge wound care orders, did not develop a pressure injury care plan, and did not follow wound physician recommendations. Staff did not consistently assess or document the resident's wounds, and the resident was later found at another facility with multiple untreated wounds. Another resident developed multiple stage 2 pressure injuries in a short period, did not receive timely pressure relief interventions, and the care plan was not updated promptly.
Seven out of eight reviewed staff members, including CNAs, an RN, an LPN, and a housekeeping staff member, did not receive required behavioral health training to care for residents with mental, psychosocial, or other behavioral health conditions. The facility lacked documentation and a policy for annual in-service training, and training provided was limited to substance use disorder, not covering the full scope of behavioral health needs.
A resident with a non-pressure wound and complex medical history did not receive physician-ordered daily wound care after a change in treatment orders. The facility only implemented the PRN aspect of the order and failed to schedule or document the required daily wound care, resulting in a lack of treatment until the wound was later identified as healed. The DON was unable to provide an explanation for this lapse.
A resident with a history of neurological and cardiac conditions, assessed as needing a two-person assist for transfers, was transferred by a single CNA using a gait belt. The CNA did not verify the required assistance level and relied on the resident's statement, resulting in the resident's legs giving out and being lowered to the floor. Documentation and staff interviews confirmed the care plan was not followed, leading to a deficiency in providing adequate supervision and assistance.
Two residents with chronic wounds did not receive appropriate enhanced barrier precautions (EBP) during wound care, as required by facility policy and CDC guidance. Nursing staff failed to wear gowns during high-contact care, were unaware of PPE locations, and did not ensure EBP signage or PPE availability near affected residents' rooms. These lapses resulted in noncompliance with infection prevention protocols.
The facility submitted inaccurate PBJ staffing data for a quarter due to staff not clocking in under the correct roles and agency staff hours not being properly recorded, resulting in reported low weekend staffing that could have affected all residents.
Failure to Provide Pressure Ulcer Care and Prevent New Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and promote the healing of pressure injuries for two residents, resulting in a deficiency. One resident was admitted with multiple diagnoses, including lymphedema, venous insufficiency, dementia, and chronic kidney disease, and had a documented stage 2 pressure injury on the right buttock upon admission. The hospital discharge summary included specific wound care instructions, but these were not incorporated into the resident's care at the facility. There was no evidence that the physician was notified of the hospital's wound care orders, and the facility did not develop or implement a comprehensive pressure injury care plan for this resident. Additionally, recommended treatments from the wound physician were not transcribed into the treatment administration record, and there was a lack of consistent and comprehensive wound assessments. Staff interviews revealed that the resident often refused care and was independent with some activities, which contributed to challenges in providing skin assessments and wound care. However, documentation and interviews indicated that staff did not consistently attempt or document thorough skin checks, particularly of the buttocks, and there was confusion among staff regarding wound locations and the staging of pressure injuries. The wound physician's recommendations were not communicated effectively, and there was a lack of follow-through in implementing treatment orders. The resident was eventually discharged to an assisted living facility, where staff identified multiple open wounds, some with signs of infection and no dressings or ointments present, leading to a hospital admission for further evaluation. A second resident developed three stage 2 pressure injuries within 15 days, and the care plan was not updated in a timely manner. The resident, who was at risk for pressure injuries, did not receive an air mattress for pressure relief for 14 days and subsequently developed an unstageable pressure injury. The facility's own policy required comprehensive assessment, timely care planning, and implementation of physician orders for wound care, but these protocols were not followed for the residents reviewed, resulting in the identified deficiencies.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that 7 out of 8 reviewed staff members received behavioral health training necessary to care for residents with mental, psychosocial, or other behavioral health conditions. Staff members including CNAs, an RN, an LPN, and a housekeeping staff member did not have documentation of having completed the required behavioral health training within the year based on their hire dates. The surveyor's review of employee records confirmed the absence of this training for these staff members. Additionally, the facility was unable to provide a policy on required annual in-service training when requested by the surveyor. Interviews with the Nursing Home Administrator (NHA) and the President of the facility's training provider revealed that while staff had received training related to substance use disorder, this was not comprehensive of all behavioral health conditions as required. The surveyor clarified that training must encompass all behaviors associated with mental illness, psychosocial, or other behavioral health conditions, not just substance use or dementia-related behaviors. The facility team acknowledged the concern, and no further documentation or information was provided to demonstrate compliance.
Failure to Provide Physician-Ordered Daily Wound Care for Non-Pressure Ulcer
Penalty
Summary
A resident with a history of lymphedema, venous insufficiency, and a non-pressure chronic ulcer of the right lower leg was admitted with a right lower extremity wound. The resident's wound care orders were changed by the physician to require daily treatment and as-needed (PRN) care, specifically to wash the right lower extremity, apply calcium alginate, cover with a 2x2 dressing, and wrap with an ace bandage. However, the facility failed to recognize and implement the scheduled daily treatment portion of the order, only documenting the PRN aspect. As a result, from the date of the new order until the wound was identified as healed, there was no evidence that the daily wound care was provided. Review of the treatment administration record (TAR) showed that the daily treatment was not scheduled or documented as completed, and there were no checks or initials indicating the treatment was provided, either daily or PRN, during this period. The Director of Nursing was unable to provide any explanation for the lack of scheduled and administered wound care according to the physician's orders. This failure resulted in the resident not receiving treatment and care in accordance with professional standards of practice for a non-pressure wound.
Failure to Provide Required Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident, who had a history of transient ischemic attack, cerebral infarction, alcohol use, depression, myocardial infarction, and congestive heart failure, was not provided with the level of assistance required for safe transfers. The resident was assessed as needing a two-person assist with a gait belt for transfers, as documented in both the care plan and therapy assessments. Despite this, the resident was transferred by a single certified nursing assistant (CNA) using a gait belt, contrary to the established care plan. During the transfer, the resident's legs gave out, and the CNA lowered the resident to the floor. The CNA did not verify the resident's transfer status prior to assisting and assumed the resident required only a one-person assist. The CNA relied on verbal information from the resident, who claimed to have been cleared for independent transfers, and did not consult the black book or electronic medical record to confirm the required assistance level. The facility's fall prevention policy required individualized care and supervision based on assessed needs, which was not followed in this instance. Documentation and interviews revealed inconsistencies in the staff's understanding and communication regarding the resident's transfer requirements. The incident report and staff statements did not consistently match, and there was no evidence that a second staff member was present during the transfer. The failure to follow the resident's care plan and provide adequate supervision and assistance directly led to the resident being lowered to the floor during the transfer.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Use During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program designed to reduce the transmission of disease and infection, as evidenced by multiple observations and interviews involving two residents with wounds requiring enhanced barrier precautions (EBP). For one resident with a left heel wound, surveyors observed that the required personal protective equipment (PPE), specifically gowns, was not worn by the Registered Nurse Unit Manager and another RN during wound care treatment. Additionally, these staff members were unaware of the current location of PPE for residents on EBP, and PPE was not readily available near or outside the resident's room as required by facility policy. The resident had a physician order for EBP due to the wound, but staff could not consistently identify or access the necessary PPE. For another resident with a stage 4 pressure injury to the left outer ankle, surveyors noted the absence of an EBP sign on the resident's door and no PPE available outside or inside the room. During a wound treatment observation, the RN performing the care did not don a gown, despite acknowledging that it was required. The resident's medical record documented a chronic wound with light serous drainage, meeting the criteria for EBP according to both facility policy and CDC guidance. However, there was no physician order for EBP for this resident, and the Director of Nursing stated that EBP was not initiated because the wound was not considered chronic and had no drainage, despite documentation to the contrary. The facility's policy, consistent with CDC and CMS guidance, requires EBP for residents with chronic wounds, such as pressure injuries, and mandates that gowns and gloves be available near or outside the resident's room for high-contact care activities. The failure to implement these precautions, ensure staff awareness of PPE locations, and properly identify residents requiring EBP led to lapses in infection control practices for both residents reviewed.
Inaccurate PBJ Staffing Data Submission Due to Timekeeping Errors
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS for the fourth quarter of 2024 was accurate. During an offsite review of the facility's payroll-based journal (PBJ) data, surveyors identified excessively low weekend staffing, which had the potential to affect all 27 residents. Upon further review of daily staff schedules from July 1, 2024, to September 30, 2024, it was noted that both licensed nurses and certified nursing assistants were present on each shift and unit, with call-ins and coverage documented. However, discrepancies were found in the PBJ data due to certain staff roles and timekeeping practices. Specifically, the facility's scheduler would sometimes fill in as a CNA on weekends but did not clock in under the CNA role, resulting in her hours being recorded as Medical Records/Scheduler instead. Additionally, the use of agency staff was not always accurately reflected in the staffing report because agency staff did not use the same time clock system, leading to unrecorded hours. These issues were attributed to the implementation of a new payroll system during the period in question and inconsistent time entry practices for agency and fill-in staff.
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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) |
|---|---|---|---|---|
| Alden Estates Of Countryside, Inc | 7.5 mi | ★★★★★ | 2 | 0 |
| Rock River Nursing & Rehab | 11.1 mi | — | 15 | 0 |
| Marquardt Memorial Manor | 12.7 mi | ★★★★★ | 21 | 0 |
| Watertown Health Care Center | 12.9 mi | ★★★★★ | 25 | 0 |
| Sun Prairie Senior Living | 17.2 mi | ★★★★★ | 23 | 0 |
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