Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lake Mills Health Services
LAKE MILLS, WI · 50 certified beds · Last Life Safety survey August 3, 2026
CMS Certification Number 525314 · first certified July 1981
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Corporation
- Ownership changed October 1, 2017 (change of ownership)from FMG MULBERRY STREET WISCONSIN LLC
Position within WI
27 citations — more than 77% 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
The latest survey found 7 citations; the earlier surveys on file averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2027 — about 10 months from now. This facility’s last Life Safety survey was August 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 519 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 about three years in Virginia. How the window is measured
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4 inspection-and-testing tags have 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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 27 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)
4 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 27 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 8, 2024 | 9 |
| March 26, 2025 | 11 |
| August 3, 2026 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2026-08-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-08-03 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2026-08-03 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2025-03-26 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2026-08-03 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 2 | 2025-03-26 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-02-08 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 1 | 2024-02-08 |
What the citations cover
- Smoke Deficiencies 11
- Emergency Preparedness Deficiencies 5
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Emergency Preparedness Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 3, 2026 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 26, 2026) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 26, 2026) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 26, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 26, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 26, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 16, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 16, 2026) |
March 26, 2025 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 10, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has plan of correction (August 1, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 14, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 31, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 16, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 16, 2025) |
February 8, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 26, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (March 21, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 21, 2024) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.