Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Willowdale Health Services
New Holstein, WI · 49 certified beds · Last Life Safety survey February 11, 2026
CMS Certification Number 525411 · first certified December 1987
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Limited Liability company
- Ownership changed October 1, 2017 (change of ownership)from FMG HOOVER STREET WISCONSIN LLC
Position within WI
20 citations — more than 58% 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 4 citations; the earlier surveys in the window averaged 8. 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 6 months from now. This facility’s last Life Safety survey was February 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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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
4 of the 20 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)
2 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 20 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 | 20 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 8, 2023 | 7 |
| October 2, 2024 | 9 |
| February 11, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-02-11 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2023-11-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2026-02-11 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-11-08 |
| E-0031 | Provide emergency officials' contact information. | 1 | 2024-10-02 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2024-10-02 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2023-11-08 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2023-11-08 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 11, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 10, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (March 10, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 24, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 10, 2026) |
October 2, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (November 2, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (November 2, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (November 2, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 2, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 2, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 2, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 2, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (November 2, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 2, 2024) |
November 8, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 8, 2023) |
| 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 (December 8, 2023) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 8, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 8, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.