Willowdale Health Services
New Holstein, Wisconsin · CCN 525411
16 surveys since 2010. The first finding at harm level was recorded in 2019.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 60
- Surveys
- 16
- Harm or worse
- 1
- Immediate jeopardy
- 1
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 49
- Ownership
- For profit - Limited Liability company
- Chain
- NORTH SHORE HEALTHCARE
- County
- Calumet
- Medicare-certified since
- 1987
CMS ratings
- Overall
- 3
- Health inspection
- 4
- Staffing
- 3
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 92 for-profit facilities with fewer than 66 beds in Wisconsin.
Last survey on record
Feb 11, 2026
271 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.47 | 3.73 |
| Registered-nurse hours per resident day | 1.09 | — |
| Annual nurse turnover | 40.0% | 45.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1881.8% | E29.1% | F29.1% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6413×
Ensure each resident receives an accurate assessment.
- F6072×
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- F6452×
PASARR screening for Mental disorders or Intellectual Disabilities
- F6902×
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- F5801×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
In the surveyor’s words
From the most serious findings on record at Willowdale Health Services, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF880Feb 11, 2026
Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmision of communicable disease and infection when 6 nursing staff (Licensed Practical Nurse (LPN)-G, LPN-L, Registered Nurse (RN)-I, Certified Nursing Assistant (CNA)-H, CNA-J, and CNA-K) did not complete required COVID-19 testing during a COVID-19 outbreak. This practice had the potential to affect all 25 residents residing in the facility.The facility had a COVID-19 outbreak that started on 1/14/26 and was still active on 2/11/26. […]
- No harm, potential for more than minimal, widespreadF812Nov 8, 2023
Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Multiple food items were expired, not dated, and/or not sealed properly. The dessert served for lunch on [DATE] was not maintained at the proper temperature during meal service and was not covered prior to service. A microwave and stove top were not kept in a clean condition. Multiple items were not stored 6 inches off the floor. The facility did not have testing logs for sanitizer buckets or the internal temperature of the dishwasher. The facility did not maintain a temperature log for the residents' refrigerator. […]
- No harm, potential for more than minimal, patternF761Oct 2, 2024
Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One medication cart was observed unlocked and unattended. In addition, 1 of 2 medication carts and 1 of 1 medication storage room contained expired medications and medical supplies. This practice had the potential to affect more than 4 of the 30 residents residing in the facility. The Chestnut hall medication cart (medication cart 1) and the medication storage room contained expired medications and medical supplies. […]
- No harm, potential for more than minimal, patternF645Nov 8, 2023
Based on staff interview and record review, the facility did not ensure 4 Residents (R) (R10, R16, R25, and R5) of 13 sampled residents met the PASRR (Pre-Admission Screen and Resident Review) requirements. R10's medical record indicated R10 had mental illness diagnoses upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen when R10 remained in the facility long term. R16's medical record indicated R16 had a mental illness diagnosis upon admission and was prescribed psychotropic medication. […]
- No harm, potential for more than minimal, isolatedF580Feb 11, 2026
Based on staff, resident, and resident representative interview and record review, the facility did not notify a Power of Attorney (POA) or family representative of a change in condition for 3 residents (R) (R33, R20, and R6) of 6 sampled residents.R33 passed away on 1/27/26. R33's family was not notified of R33's passing in a timely manner.R20 was diagnosed with COVID-19 on 2/2/26 and was moved to a private room for isolation protocol. R20's POA was not notified of the diagnosis or room change until 2/4/26.R6 was diagnosed with COVID-19 on 1/29/26. […]
Read 21 findings in full →The most serious and the most recent: 21 of 60 on record.
Every survey on record
FindingsAt actual harm or above
- Feb 11, 2026Standard6 findings
- Jan 22, 2025Complaint1 finding
- Oct 2, 2024Standard and complaint7 findings
- Nov 8, 2023Standard5 findings
- Oct 12, 2022Standard3 findings
- Dec 21, 2020Infection control1 finding
- Nov 14, 2019Standard5 findings · 1 harm
- Oct 11, 2018Standard4 findings
Show the 8 earlier surveys
- Aug 22, 2017Standard5 findings
- Jun 15, 2016Standard3 findings
- Mar 12, 2015Standard3 findings
- Apr 11, 2014Complaint1 finding
- Mar 20, 2014Standard2 findings
- Jan 29, 2013—6 findings
- Jan 26, 2012—6 findings
- Dec 3, 2010—2 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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