Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

A
Grade
70
Score
CMS Ratings
16.9/22
Staffing Quality
16.6/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate56.6%
50
Total Beds
28
Occupied
22
Available

Basic Information

Address:

901 MULBERRY ST

LAKE MILLS, WI 53551

Number of Beds:

50

Estimated Occupancy:

57% (~22 available)

Chain:

NORTH SHORE HEALTHCARE

Quality Ratings

Overall Rating:4/5 Stars
Health Inspection:4/5 Stars
Staffing Rating:4/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

525314

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Above Average

This Facility

1.52

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Average

This Facility

3.54

hours

National Avg

3.89

hours

Breakdown:

RN: 1.52hLPN: 0.17hAide: 1.85h

Staff Turnover Rate

Annual nursing staff turnover

Below Average

This Facility

37.9%

National Avg

46.6%

RN Turnover: 30.8%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

26

Inspections

4

Mar 26, 2025 - Health Survey

6 deficiencies cited

Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 14, 2025
Low - IsolatedTag F0851

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected: Apr 14, 2025
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Apr 14, 2025
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 14, 2025
Low - IsolatedTag F0851

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected: Apr 14, 2025
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Apr 14, 2025

Feb 8, 2024 - Health Survey

4 deficiencies cited

Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Mar 8, 2024
Medium - PatternTag F0882

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected: Mar 8, 2024
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Mar 8, 2024
Medium - PatternTag F0882

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected: Mar 8, 2024

Oct 10, 2023 - Health Survey

6 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Nov 9, 2023From Complaint

Oct 17, 2022 - Health Survey

10 deficiencies cited

Low - IsolatedTag F0572

Resident Rights Deficiencies

Give residents a notice of rights, rules, services and charges.

Corrected: Nov 11, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Nov 11, 2022
Low - IsolatedTag F0572

Resident Rights Deficiencies

Give residents a notice of rights, rules, services and charges.

Corrected: Nov 11, 2022
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Nov 11, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Nov 11, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Nov 11, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Nov 11, 2022
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Nov 11, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Nov 11, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Nov 11, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

1 penalty in the past 3 years

Total fines: $120,900

FineJuly 3, 2025

$120,900

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

High CMS Rating
4 out of 5 stars from Medicare
👨‍⚕
Above Average RN Staffing
1.52 RN hours per resident/day (national avg: 0.64)
Low Staff Turnover
37.9% (national avg: 46.6%)
🛏
Beds Available
Approximately 22 beds potentially available
🏢
Part of Healthcare Chain
NORTH SHORE HEALTHCARE

Frequently Asked Questions

What is the quality rating for Lake Mills Health Services?

Lake Mills Health Services has an overall CMS rating of 4 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

Lake Mills Health Services has 50 certified beds. The facility averages 28 residents per day, with an occupancy rate of approximately 57%.

What type of ownership does this facility have?

This facility is for profit - corporation owned. It is part of the NORTH SHORE HEALTHCARE network.

How can I contact Lake Mills Health Services?

You can call Lake Mills Health Services at (920)648-8344. The facility is located at 901 MULBERRY ST, LAKE MILLS, WI 53551.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

Important Considerations for This Facility

Based on this facility's data, we recommend reading these guides to understand what to look for:

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