Williams Bay Health Services

Inspection findings

1. Jun 3, 2026 Fire Safety · 35 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity C

     F0575 Resident Rights Deficiencies

     Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

     Corrected Jul 7, 2026 · 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 Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     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 Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jul 7, 2026 · CMS health inspection

   • Serious Scope/severity J

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Jul 7, 2026 · CMS health inspection

   • Serious Scope/severity G

     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 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0691 Quality of Life and Care Deficiencies

     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0726 Nursing and Physician Services Deficiencies

     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0740 Quality of Life and Care Deficiencies

     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0745 Quality of Life and Care Deficiencies

     Provide medically-related social services to help each resident achieve the highest possible quality of life.

     Corrected Jul 7, 2026 · 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 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 7, 2026 · 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 Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Jul 7, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jul 2, 2026 · 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 Jul 2, 2026 · CMS fire safety

2. Jan 26, 2026 Health · 1 finding
   • 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 Feb 23, 2026 · CMS health inspection

3. Mar 27, 2025 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0036 Emergency Preparedness Deficiencies

     Establish emergency prep training and testing.

     Corrected Apr 22, 2025 · CMS fire safety

   • Serious Scope/severity G

     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 24, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0697 Quality of Life and Care Deficiencies

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

     Corrected Apr 24, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 24, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0909 Environmental Deficiencies

     Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

     Corrected Apr 24, 2025 · 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 Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Apr 24, 2025 · CMS fire safety

4. Jan 25, 2024 Fire Safety · 8 findings
   • Not serious Scope/severity E

     K0161 Construction Deficiencies

     Use approved construction type or materials.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0342 Smoke Deficiencies

     Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 21, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Feb 21, 2024 · CMS fire safety

5. Sep 22, 2023 Health · 3 findings
   • Not serious Scope/severity D 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 Oct 23, 2023 · CMS health inspection

   • 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 Oct 23, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 23, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 12/01/2019
• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 10/01/2019
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 12/01/2019
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• 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 — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 12/01/2019
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 10/01/2019
• MILLS, DAVID — 5% or greater indirect ownership interest, 18%, since 10/01/2019
• 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 12/01/2019
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 12/01/2019
• SCHELLHORN, KATHERINE — operational/managerial control, NOT APPLICABLE, since 06/03/2024
• SCHELLHORN, KATHERINE — adp of the snf, NOT APPLICABLE, since 06/03/2024
• SIDHU, SARFRAZ — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• SIDHU, SARFRAZ — adp of the snf, NOT APPLICABLE, since 01/01/2023
• ARROWHEAD 123 LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• ARROWHEAD 123 LLC — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — 5% or greater mortgage interest, NOT APPLICABLE, since 12/31/2024
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 06/09/2025
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 06/09/2025
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 06/09/2025
• NSH 146 CLOVER STREET LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 06/09/2025
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSHR OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 10/01/2019
• THE LANE MORRELL BOWEN TRUST — adp of the snf, NOT APPLICABLE, since 12/01/2019
• THE LANE MORRELL BOWEN TRUST — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 06/09/2025