Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowdale Health Services during CMS and state inspections, most recent first.
An infection prevention and control deficiency occurred when multiple nursing staff did not complete required COVID-19 testing during an active outbreak and did not document results before working shifts. The facility’s policy required routine testing during the outbreak, but an LPN, RN, and several CNAs missed required tests over multiple days, and the DON and NHA were unaware the testing and training requirements had not been followed.
Failure to Notify Resident Representatives of Changes in Condition: The facility did not timely notify family/POA contacts about changes in condition for 3 residents. One resident with intact cognition died, but family was not notified promptly. Another resident with severe cognitive impairment and an activated POA was diagnosed with COVID-19 and moved to isolation, but the POA was not informed right away. A third resident with intact cognition and a requested POA contact had a positive COVID-19 test, but the representative was not documented as being notified timely.
Incorrect MDS Documentation of Serious Mental Illness: The facility completed inaccurate MDS assessments for two residents by failing to properly reflect serious mental illness in Section A1500. One resident had bipolar mood disorder and anxiety, and another had bipolar disorder, anxiety, and major depression; both had BIMS scores of 15/15 and made their own decisions, yet the MDSs stated they did not have a serious mental illness. Leadership and the SW reviewed the records and confirmed the assessments were incorrect.
PASRR screening was not completed correctly for two residents with diagnoses including bipolar disorder, anxiety, and major depression. One resident’s PASRR Level I screen incorrectly showed no mental illness, and the NHA and DON verified a PASRR Level II screen should have been completed. For the other resident, the medical record lacked a PASRR Level II screen and county exemption paperwork, and the SW confirmed the Level II screen was only completed after the surveyor requested it.
A resident with dementia and Alzheimer's disease had a BIMS score indicating moderate cognitive impairment, and a hospital discharge summary noted baseline cognitive impairment with difficulty following cues and impaired safety awareness during transfers and ADLs. Review of the care plan and Kardex showed no dementia-related goals or interventions, and both a CNA and RN confirmed the resident's plan of care did not address dementia.
Pressure Reducing Mattress Set Incorrectly for Resident With Stage 3 Pressure Injury. A resident admitted with a stage 3 pressure injury to the left buttock had an order for a pressure reducing mattress set at 150 pounds, but surveyors observed the mattress set at 200 pounds on multiple occasions. The resident was also found in a bed without the ordered pressure reducing mattress, and staff interviews confirmed the mattress setting was incorrect and locked at the higher setting.
A facility failed to update a care plan for a resident with behavioral issues after an incident where the resident allegedly hit another resident. The intervention to serve meals outside the dining room was meant to be short-term but remained in the care plan without a review date or monitoring to prevent involuntary seclusion. The resident's behaviors had improved, but the care plan was not revised.
A medication cart was found unlocked and unattended, and expired medications and supplies were discovered in a medication cart and storage room. These issues were confirmed by nursing staff, who acknowledged that the facility's policy requires medication carts to be locked and expired items to be disposed of.
A facility failed to report an allegation of mistreatment involving a resident with moderate cognitive impairment to the State Agency. The incident involved a CNA making inappropriate noises during perineal care, which was reported by another CNA to the charge nurse. Despite the facility's policy requiring immediate reporting of such allegations, the Nursing Home Administrator did not report the incident to the State Agency.
A facility failed to thoroughly investigate an allegation of mistreatment involving a resident and a CNA. The incident involved inappropriate behavior during perineal care, reported by another CNA. The investigation was insufficient, lacking interviews with the resident and other staff, and did not include educational measures. The resident had moderate cognitive impairment and was dependent on staff for care.
The facility did not adhere to its policy requiring out-of-state background checks for potential employees, as evidenced by the hiring of a CNA who had lived out of state without completing the necessary checks. This lapse was identified during a compliance check and confirmed by the NHA, who admitted the oversight.
A resident with bipolar disorder and dementia was inaccurately assessed in their MDS, as it failed to reflect their hallucinations and delusions. The MDS Coordinator and Social Worker did not review a nursing note indicating these symptoms, leading to an incorrect assessment.
A facility failed to prevent urinary tract infections for a resident with an indwelling catheter. The resident's catheter drainage bag was observed uncovered and in contact with the floor, contrary to the facility's policy requiring bags to be covered and not touch the floor. Staff interviews confirmed the deficiency, highlighting a lapse in adherence to catheter care guidelines.
A resident with colorectal cancer experienced significant weight loss, but the facility failed to notify the RD and physician or implement interventions. Despite the facility's policy, the resident's weight loss was not addressed, leading to a 13.18% weight loss over 30 days.
Failure to Ensure Required COVID-19 Testing During Outbreak
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection when 6 nursing staff members did not complete required COVID-19 testing during an active COVID-19 outbreak. The outbreak began on 1/14/26 and was still active on 2/11/26. The facility’s COVID-19 Prevention, Response and Reporting policy, revised 12/8/25, required viral testing for COVID-19 per national standards, and CDC guidance cited in the report called for routine testing of healthcare personnel with higher risk of exposure during an outbreak. Survey review found that LPN-G, LPN-L, RN-I, CNA-H, CNA-J, and CNA-K did not test for COVID-19 every other day and did not document results in accordance with facility policy before working scheduled shifts. Specifically, LPN-G did not complete tests from 2/4/26 through 2/8/26, CNA-H did not complete tests from 2/4/26 through 2/10/26, RN-I did not complete a test on 2/4/26, CNA-J did not complete tests from 2/4/26 through 2/10/26, CNA-K did not complete a test on 2/6/26, and LPN-L did not complete tests on 2/7/26 or 2/8/26. The DON stated the facility’s procedure was for staff to complete a COVID-19 test and document the name, date, time, and result prior to clocking in, but the facility did not have a system to ensure staff completed the testing. The DON and NHA were also not aware that CNA-H had not completed COVID-19 testing training on 2/4/26.
Failure to Notify Resident Representatives of Changes in Condition
Penalty
Summary
The facility failed to notify residents’ representatives of changes in condition for 3 residents. R33, who had Parkinson’s disease, prostate cancer, chronic kidney disease stage 3, and COVID-19, had intact cognition and was his own decision maker, but his family was not notified in a timely manner when he died. The medical record did not show that his family was notified of his passing, and the grievance file documented the family’s concern that they were not notified when he died. R20 had severely impaired cognition with a BIMS score of 3 and an activated POA. After R20 was diagnosed with COVID-19 and moved to a private room for isolation, the POA was not notified of the diagnosis or room change until 2 days later. A progress note documented that the POA had not been notified on the day of the diagnosis and room change, and the grievance file reflected the POA’s complaint that notification had not occurred. R6 had diagnoses including diabetes and stroke and had intact cognition with a BIMS score of 15. Although R6 requested that the designated POA be notified of changes, the medical record did not show that the POA was notified of R6’s positive COVID-19 test. The physician was notified, but the resident’s representative was not documented as being informed, and the POA reported being notified by the resident first and then by the facility several days later.
Incorrect MDS Documentation of Serious Mental Illness
Penalty
Summary
The facility did not ensure accurate MDS assessments for two residents by incorrectly completing Section A1500 related to serious mental illness. The facility’s Resident Assessment-Coordination with PASRR Program stated that all applicants would be screened for serious mental disorders or intellectual disabilities in accordance with state Medicaid rules, including Level I screening before admission and Level II evaluation when indicated. R8 was admitted with diagnoses including bipolar mood disorder and anxiety. Although R8’s MDS assessment dated 1/27/26 showed a BIMS score of 15 out of 15, indicating intact cognition, and noted that R8 made R8’s own medical decisions, the assessment stated that R8 did not have a serious mental illness. During interview on 2/11/26, the NHA and DON reviewed the assessment and verified that R8 had a mental illness that should have been reflected in Section A1500. R4 was admitted with diagnoses including bipolar disorder, anxiety, and major depression. R4’s MDS assessment dated 11/13/25 also showed a BIMS score of 15 out of 15 and indicated R4 made R4’s own healthcare decisions, but it stated that R4 did not have a serious mental illness. During review on 2/10/26, the VPS and SW reviewed Section A1500 and confirmed the assessment was incorrect; the SW stated Section A1500 should have been documented as not assessed.
PASRR Screening Not Completed for Two Residents With Mental Illness Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for two residents who had diagnoses associated with mental illness. One resident was admitted with bipolar mood disorder and anxiety, had a BIMS score of 15 out of 15, was documented as having intact cognition, and made his or her own medical decisions. The resident’s PASRR Level I screen incorrectly indicated no mental illness despite the bipolar mood disorder diagnosis. During interview, the NHA and DON verified that the resident had a mental illness that should have been documented on the PASRR Level I screen and that a PASRR Level II screen should have been completed and submitted for review. A second resident was admitted with bipolar disorder, anxiety, and major depression, had a BIMS score of 15 out of 15, was documented as having intact cognition, and made his or her own healthcare decisions. The resident’s medical record did not contain a PASRR Level II screen or county exemption paperwork. When the surveyor requested the PASRR Level II screen, the SW confirmed it was completed only after the request was made and stated the PASRR Level I screen should have indicated a serious mental illness. The SW also verified the facility did not have a copy of the county exemption paperwork.
Failure to Include Dementia Care Interventions in Care Plan
Penalty
Summary
The facility did not ensure a comprehensive resident-centered dementia care plan was implemented for one resident with diagnoses of dementia and Alzheimer's disease. The resident's MDS assessment dated 12/2/25 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and identified dementia and Alzheimer's disease as active diagnoses. A hospital discharge summary also noted baseline cognitive impairment that contributed to difficulty following cues during therapy and impaired safety awareness during transfers and ADLs. On 2/11/26, review of the resident's comprehensive care plan showed it did not contain dementia-related goals or interventions, and the resident's Kardex also lacked dementia-related interventions. A CNA stated the resident had behaviors when first admitted but had not shown recent behaviors, and confirmed the care plan and Kardex did not address dementia. An RN confirmed the care plan did not address dementia and stated that if dementia-related concerns were present, interventions would be added; the RN also stated a baseline care plan is developed upon admission.
Pressure Reducing Mattress Set Incorrectly for Resident With Stage 3 Pressure Injury
Penalty
Summary
R5 was admitted with a stage 3 pressure injury on the left buttock and had diagnoses including diabetes with chronic kidney disease, protein-calorie malnutrition, and metabolic encephalopathy. The resident’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition, and the resident made their own medical decisions. The medical record showed the left buttock pressure injury measured 3 cm by 2.5 cm by 0.1 cm on 12/23/25 and 3 cm by 4 cm by 0.1 cm on 2/9/26. The record contained an order for a pressure reducing mattress to be set at 150 pounds, and the MAR indicated the setting should be documented every shift. During observations on 2/9/26 and 2/10/26, Surveyor found R5’s pressure reducing mattress set at 200 pounds. On 2/11/26, Surveyor observed R5 in a bed without the ordered pressure reducing mattress, and DON-B verified the resident was not in the correct bed. Staff interviews confirmed the mattress was locked at 200 pounds instead of the ordered 150 pounds, and RN-P adjusted it to the correct setting after reviewing the MAR.
Failure to Revise Care Plan Intervention for Resident
Penalty
Summary
The facility failed to review and revise a care plan intervention for a resident, R2, following an incident where R2 allegedly hit another resident, R1, in the dining room. The intervention implemented was to serve R2 meals in R2's room or anywhere other than the dining room, intended as a short-term measure. However, the care plan did not specify a time frame for this intervention, nor did it include monitoring to ensure R2 was not being involuntarily secluded from other residents. This oversight was identified during a surveyor's review of R2's medical record and the facility-reported incident. R2 had a history of dementia with behavioral disturbance, anxiety, bipolar disease, and delusional disorder, and was monitored for behaviors such as refusal of care, aggression toward staff, and yelling. Despite the intervention being meant for short-term use, it remained on R2's care plan without a stop or review date. The Nursing Home Administrator confirmed that the intervention was not updated to reflect its temporary nature and lacked monitoring to prevent involuntary seclusion. R2's behaviors had improved since the incident, yet the care plan was not revised accordingly.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored according to their policy, leading to a deficiency. During an observation, a medication cart in the Chestnut hall was found unlocked and unattended, which is against the facility's policy that requires medication carts to be locked when not in use or attended by authorized personnel. This lapse in security was confirmed by interviews with the Registered Nurse and the Assistant Director of Nursing, who acknowledged that the medication cart should have been locked. Additionally, expired medications and medical supplies were found in one of the medication carts and the medication storage room. The expired items included a container of Milk of Magnesia, a bottle of Fiber Laxative, a povidone-iodine swab stick, a syringe with a hypodermic needle, and several packages of arginine powder. These findings were verified by a Licensed Practical Nurse and the Assistant Director of Nursing, who confirmed that the expired items should have been disposed of according to the facility's procedures.
Failure to Report Alleged Mistreatment to State Agency
Penalty
Summary
The facility failed to report an allegation of mistreatment involving a resident, identified as R23, to the State Agency (SA) as required by their policy. The incident involved a Certified Nursing Assistant (CNA), referred to as CNA-J, who allegedly made inappropriate noises while providing perineal care to R23. This incident was witnessed by another CNA, identified as CNA-I, who reported feeling that the behavior was inappropriate and subsequently reported it to the charge nurse. Despite this report, the Nursing Home Administrator (NHA) did not ensure that the allegation was reported to the SA, which is a violation of the facility's policy on abuse, neglect, and exploitation. R23, who was admitted with diagnoses including a displaced fracture, dementia, and congestive heart failure, was assessed to have moderate cognitive impairment. The facility's policy mandates that any allegations of abuse or mistreatment be reported immediately, or within 24 hours if the incident does not involve abuse or serious bodily injury. However, the NHA, who was on vacation at the time, acknowledged that the incident was not reported to the SA, despite being aware of the situation. This oversight represents a failure to adhere to the established protocols for reporting suspected abuse or mistreatment, as outlined in the facility's policy.
Inadequate Investigation of Mistreatment Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of mistreatment involving a resident, identified as R23, and a Certified Nursing Assistant (CNA), referred to as CNA-J. The incident in question occurred on 6/24/24, when CNA-I reported that CNA-J made inappropriate noises while providing perineal care to R23. The facility's investigation was insufficient as it only included a competency checklist for CNA-J and lacked interviews with the resident, other staff members, and specifically CNA-I, who initially reported the incident. The investigation also did not include any educational measures for other staff members. R23, who was admitted with diagnoses including a displaced fracture of the left acetabulum, dementia, and congestive heart failure, was dependent on staff for toileting and hygiene. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment. Despite the report from CNA-I, the Nursing Home Administrator (NHA) acknowledged that the investigation was not thorough, as it was conducted while the NHA was on vacation, and there was a noted discrepancy regarding the incident's timeframe.
Failure to Conduct Out-of-State Background Check for CNA
Penalty
Summary
The facility failed to consistently implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents. This deficiency was identified during a caregiver program compliance check, where it was found that the facility did not complete an out-of-state background check for a Certified Nursing Assistant (CNA), referred to as CNA-K, who had lived out of state before moving to Wisconsin. Despite the facility's policy, dated 7/15/22, which mandates background checks for potential employees, including those who have lived out of state, the facility only conducted a background check through the Wisconsin Department of Justice, omitting the necessary federal or out-of-state check. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to perform the required checks prior to CNA-K's hiring.
Inaccurate MDS Assessment for Resident with Hallucinations
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident with a history of bipolar disorder and dementia with psychotic features. The resident's Quarterly MDS assessment indicated that the resident did not have delusions or hallucinations, despite a nursing note on the same date stating that the resident experienced visual and auditory hallucinations and frequently reacted to internal stimuli. This discrepancy was identified during a surveyor's review of the resident's medical record. The MDS Coordinator acknowledged that the assessment was based on point-of-care documentation and did not include the nursing note that documented the resident's hallucinations. The Social Worker responsible for completing the relevant section of the MDS was unaware of the resident's symptoms during the assessment period and had not reviewed the nursing note. The Social Worker stated that if they had seen the note, they would have coded the MDS assessment differently, indicating the presence of hallucinations and delusions.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling catheter. During an observation, the resident's uncovered catheter drainage bag was found attached to their wheelchair and in contact with the floor. This was contrary to the facility's catheter care policy, which mandates that catheter drainage bags should be covered and not touch the floor to prevent contamination and maintain the resident's dignity and privacy. The deficiency was confirmed through interviews with facility staff, including a CNA, an RN, the Assistant Director of Nursing, and the Nursing Home Administrator, all of whom acknowledged that catheter bags should not be in contact with the floor and should be covered with a dignity bag. The facility's policy and Relias training emphasize the importance of proper catheter care to prevent infections, yet the observed practice did not align with these guidelines.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent significant weight loss for a resident, identified as R17, who experienced a 7.38% weight loss over a period of approximately two weeks. Despite the facility's policy requiring notification of the Registered Dietitian (RD) and physician for significant weight changes, neither was informed of R17's weight loss. The resident's medical record lacked any dietitian notes or progress notes after the initial assessment, and no interventions or supplements were offered to address the weight loss. R17, a short-term hospice patient with colorectal cancer, was admitted with a history of inadequate oral intake. The facility's weight monitoring policy required regular weight checks and notifications for significant changes, but these protocols were not followed. The RD, who visited the facility bi-weekly, did not review R17's significant weight loss due to a system failure in triggering alerts. Consequently, R17's weight continued to decline, resulting in a 13.18% weight loss over just over 30 days, without appropriate interventions being implemented.
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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 New Holstein
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homestead Health Services | 0.7 mi | ★★★★★ | 14 | 0 |
| Rocky Knoll Health Care | 11.2 mi | ★★★★★ | 6 | 0 |
| Plymouth Health Services | 14.9 mi | ★★★★★ | 1 | 0 |
| Sheboygan Senior Community Inc | 18.6 mi | ★★★★★ | 16 | 0 |
| Complete Care At Manitowoc Llc | 19.2 mi | ★★★★★ | 6 | 0 |
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