Lake Country Health Services

Penalties

• Mar 12, 2025 — Fine ($16,985)
• Nov 4, 2024 — Fine ($103,883)
• Nov 4, 2024 — Payment Denial · payment denial 8 days

Inspection findings

1. Aug 27, 2025 Health · 6 findings
   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Sep 16, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 16, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Sep 16, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Sep 16, 2025 · CMS fire safety

2. Mar 12, 2025 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Apr 2, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Apr 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 2, 2025 · CMS health inspection

3. Nov 4, 2024 Health · 14 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Dec 12, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0620 Resident Rights Deficiencies

     Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0660 Resident Assessment and Care Planning Deficiencies

     Plan the resident's discharge to meet the resident's goals and needs.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Dec 12, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 12, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     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 Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0825 Quality of Life and Care Deficiencies

     Provide or get specialized rehabilitative services as required for a resident.

     Corrected Dec 12, 2024 · CMS health inspection

4. Jun 20, 2024 Health · 16 findings
   • Not serious Scope/severity E

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     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 Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jul 11, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Jul 10, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jul 2, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jul 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0522 Services Deficiencies

     Have an externally vented heating system.

     Corrected Jul 19, 2024 · CMS fire safety

5. Feb 29, 2024 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     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 Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Mar 26, 2024 · CMS health inspection

6. Oct 9, 2023 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 8, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 8, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Nov 8, 2023 · CMS health inspection

7. Apr 12, 2023 Health · 11 findings
   • Not serious Scope/severity D

     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 May 10, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected May 10, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected May 10, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected May 10, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 10, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 10, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected May 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 10, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected May 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 10, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 10/01/2017
• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 06/29/2017
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 11/01/2019
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 11/01/2019
• GEE, DARREN — operational/managerial control, NOT APPLICABLE, since 11/30/2021
• GEE, DARREN — adp of the snf, NOT APPLICABLE, since 11/30/2021
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• HAMM, CARA — operational/managerial control, NOT APPLICABLE, since 01/01/2026
• HAMM, CARA — adp of the snf, NOT APPLICABLE, since 01/01/2026
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 10/01/2017
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 06/29/2017
• MILLS, DAVID — 5% or greater indirect ownership interest, 20%, since 06/29/2017
• PATZER, COLLEEN — adp of the snf, NOT APPLICABLE, since 02/14/2023
• PATZER, COLLEEN — operational/managerial control, NOT APPLICABLE, since 02/14/2023
• PURTELL, BRIAN — operational/managerial control, NOT APPLICABLE, since 06/01/2018
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 06/01/2018
• RAMNANAN, KESHNI — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• RAMNANAN, KESHNI — adp of the snf, NOT APPLICABLE, since 01/01/2023
• CANYON WOH, LLC — adp of the snf, NOT APPLICABLE, since 10/21/2022
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/03/2025
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/03/2025
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 04/15/2025
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 05/22/2018
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 04/15/2025
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2017
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 04/15/2025
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 06/13/2025
• NSHF OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 07/24/2017
• NSHW WISCONSIN LLC — adp of the snf, NOT APPLICABLE, since 05/12/2025
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 04/15/2025