Lake Mills Health Services

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 12, 2021

  Based on record review, interview and observation, the facility did not follow professional standards of practice and its own written policies and procedures designed to help prevent the development and transmission of COVID-19 (Coronavirus Disease 2019), potentially affecting all 29 residents who resided at the facility at the time of the survey. * CNA (Certified Nursing Assistant)-M was not screened upon starting her work shift and later developed signs and symptoms and tested positive for COVID-19. CNA-M was identified by the facility as the index case for the facility's outbreak of COVID-19 that began on 12/23/20. * Facility staff were screened at the start of their shift and found to have signs and symptoms of COVID-19. […]

• Immediate jeopardy, isolatedF686Jul 3, 2025

  Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R1 andR4) of 3 residents reviewed for pressure injuries. * R1 admitted to the facility on [DATE] with a hospital discharge summary that included treatment for R1’s right ischium. This treatment was not picked up by the facility. On 5/14/25, the facility documented a stage 2 pressure injury (PI) to R1’s right buttock. Wound Physician-G’s treatment recommendation for the right buttock was not completed by the facility. […]

• Immediate jeopardy, isolatedF622Mar 22, 2022

  Based on record review and resident and staff interviews, the facility did not ensure a safe discharge for 1 Resident (R) (R1) of 1 resident. reviewed for discharge. R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, R1 required staff assistance with ADLs (activities of daily living) such as bathing, dressing and personal hygiene. R1's care plan indicated R1 had poor safety awareness and judgement. When R1's skilled nursing coverage ended on 2/23/22, R1 was eligible to remain in the facility under custodial care for a total of 90 days until R1 could disenroll from R1's HMO (health maintenance organization) and transition to straight Medicaid. Despite notification from R1's HMO that R1's stay was covered, the facility discharged R1 to a homeless shelter. […]

• Immediate jeopardy, isolatedF745Mar 22, 2022

  Based on record review and resident and staff interview, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 Resident (R) (R1) of 1 resident. When R1's skilled nursing coverage ended on 2/23/22, R1's HMO (health maintenance organization) informed the facility via fax and voicemails that R1 was eligible to remain in the facility under custodial care. The fax was not acknowledged and the voicemails went unreturned. In addition, a copy of the notice of denial of skilled coverage with information on appeal rights was not provided to R1 and the ADRC was not contacted on R1's behalf. […]

• Actual harm, isolatedF686Aug 3, 2026

  Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R20 and R3) of 4 residents reviewed for pressure injuries. *R20 has a history of pressure injuries and is at risk for developing pressure injuries. Facility staff did not put resident-specific care plan interventions in place to prevent the development of pressure injuries. R20 developed a stage 3 pressure injury to R20's left outer ankle. *R3 did not receive care to prevent the development of an unstageable pressure injury (PI) to R3's left foreskin. […]