Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LAKELAND HEALTH CARE CTR

ELKHORN, WI · 90 certified beds · Last Life Safety survey January 26, 2026

CMS Certification Number 525625 · first certified August 1997

Ownership

Independently operated (no chain recorded by CMS) · Government - County

No change of ownership on CMS record since January 1, 2016, when the records begin.

17
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within WI

17 citations — more than 47% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens March 2027 — about 5 months from now. This facility’s last Life Safety survey was January 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility17WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility17
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
62023-0672024-0842026-01
Citations at each Life Safety survey
Survey dateCitations
June 7, 20236
August 29, 20247
January 26, 20264

Most-cited tags

Most-cited tags at this facility
K-03453K-03512K-03241E-00241K-07121K-03741K-03531K-03551
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32026-01-26
K-0351Install an approved automatic sprinkler system.22026-01-26
K-0324Provide properly protected cooking facilities.12024-08-29
E-0024Establish policies and procedures for volunteers.12023-06-07
K-0712Have simulated fire drills held at unexpected times.12024-08-29
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.12024-08-29
K-0353Inspect, test, and maintain automatic sprinkler systems.12023-06-07
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12026-01-26

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 12
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Emergency Preparedness Deficiencies 2
  • Miscellaneous Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies12
Gas, Vacuum, and Electrical Systems Deficiencies2
Emergency Preparedness Deficiencies2
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 26, 2026 — 4 citations

Citations issued on January 26, 2026
TagWhat the surveyor checksStatus
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (February 2, 2026)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (January 28, 2026)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has plan of correction
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (February 12, 2026)

August 29, 2024 — 7 citations

Citations issued on August 29, 2024
TagWhat the surveyor checksStatus
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (September 27, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (September 20, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 18, 2024)
K-0351Install an approved automatic sprinkler system.Waiver has been granted
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (September 18, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (September 20, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (September 19, 2024)

June 7, 2023 — 6 citations

Citations issued on June 7, 2023
TagWhat the surveyor checksStatus
E-0024Establish policies and procedures for volunteers.Deficient, Provider has date of correction (June 23, 2023)
K-0342Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.Deficient, Provider has date of correction (July 7, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (June 19, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 20, 2023)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (June 19, 2023)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (June 23, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.