Lake Mills Care Center

In the surveyor’s words

From the most serious findings on record at Lake Mills Care Center, in the surveyor’s own words.

• Actual harm, isolatedF697Oct 16, 2025

  Based on record review, policy review and staff interviews, the facility failed to promptly identify, intervene and notify the provider of an acute change in a resident's uncontrolled pain following a fall on 7/21/25 for 1 of 3 residents reviewed (Resident #1). On 7/21/25 at 4:00 AM, Resident #1 had a witnessed fall. When the nurse assessed her, she reported pain to her leg but had range of motion to her legs. After transferring the resident to the bed, the resident reported an increase in pain reporting it was the worst pain ever. The nurse faxed the physician instead of sending her for evaluation. The resident continued to put her call light on seven times between 4:50 AM to 5:15 AM reporting to staff severe pain. […]

• No harm, potential for more than minimal, patternF812Apr 15, 2026

  Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to protect residents from pathogens when they stored food in an unhygienic manner and when they assisted residents with eating using unsanitary practices. The facility reported a census of 39. Findings include: The Minimum Data Set (MDS) for Resident #29, dated 02/07/2026, documented the following relevant diagnoses: Alzheimer's disease, Non-Alzheimer's dementia, Dysphagia Oropharyngeal Phase (difficulty swallowing). It documented the resident required substantial/maximal assistance in eating. The MDS for Resident #33, dated 03/06/2026, documented the following relevant diagnoses: Non-Alzheimer's dementia. […]

• No harm, potential for more than minimal, patternF756May 4, 2023

  Based on interviews and record reviews, the facility failed to develop and implement a medication regimen review (MMR) policy and procedure with time limits for steps in the Medication Regimen Review (MRR) process with the steps the pharmacist must take when an irregularity requires urgent action. The facility's deficient practice increased the 49 residents residing at the facility's risk of medication errors/adverse medication consequences. Findings include: Review of Haloperidol .[NAME] Pharmaceuticals, Inc . on the website National Library of Medicine revealed .Warning: Increased Mortality in Elderly Patients .Haloperidol tablets are indicated for use in the management of manifestations of psychotic disorders .Haloperidol tablets are contraindicated .Parkinson's disease . […]

• No harm, potential for more than minimal, patternF761May 4, 2023

  Based on observations, interviews, and review of the facility policy, the facility failed to ensure one of one medication room, did not store one medication bottle with faded, and unreadable label, contained twenty-three expired syringes with needles, and the medication refrigerator temperatures were logged/documented properly. The facility deficient practice increased the 49 residents residing at the facility at risk of medication errors. Findings include: Review of the facility's policy titled Drug Labeling dated ,d+[DATE] revealed to assure appropriate drug labeling procedures .Floor stocked nonprescription medication containers must identify at minimum brand name or genic name and manufacturer, strength, lot number and expiration date . […]

• No harm, potential for more than minimal, patternF812May 4, 2023

  Based on observations, interview, record review and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 49 out of 49 residents. Failure to keep sanitary conditions in the kitchen has the potential to spread foodborne pathogens among residents. Specifically, food items in the kitchen and storage areas were expired, unlabeled and/or undated and kitchen equipment was coated in a white residue. Findings include: Review of the facility's policy titled, Refrigerated Food Storage dated [DATE], revealed, Refrigerated foods received, stored, prepared and served, will be properly labeled, dated and used or discarded according to the regulatory requirements and maintenance of food quality. […]