Report
TheVardellReport
Lake Country Health Services
Skilled nursing facility and nursing facility
2195 North Summit Village Way
Oconomowoc, WI 53066
Report
← Lake Country Health Services, free profile
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The Vardell Report.Lake Country Health Services
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Oconomowoc, WI
- Record Period
- 2023–2025
- Source Documents
- 9
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from April 2023 to August 2025, state surveyors documented 42 findings at Lake Country Health Services; 42 have a recorded correction; CMS lists 3 enforcement actions in the window.
- Inspections
- 7
- 2023–2025, standard and complaint
- Findings
- 42
- Deficiencies cited by state inspectors
- Corrected
- 42
- Of 42 findings, with a recorded correction date
- Penalties
- 3
- 2 fines; payment not published, 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 9 | 0 |
| 2024 | 3 | 28 | 3 |
| 2025 | 2 | 5 | 1 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 42 of 42 findings have a recorded correction date.
- CMS lists 3 enforcement actions in the window: 2 fines totaling $120,868, their payment not published; denial of payment imposed November 4, 2024, ended December 12, 2024.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, August 27, 2025, recorded 2 findings (most serious: Level D).
What to Ask About
- Telling Families About Changes, Cited in Two Inspections
- Reporting Suspected Abuse, Cited in Two Inspections
- Investigating Alleged Violations, Cited in Two Inspections
- Help With Daily Living, Cited in Two Inspections
- Citation F678, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Pharmacy Services, Cited in Two Inspections
- Medication Error Rate, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Medical Records, Cited in Two Inspections
Report at a Glance
- Facility
- Lake Country Health Services
- Address
- 2195 North Summit Village Way, Oconomowoc, WI 53066
- CMS Certification Number
- 525702
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 100
- Ownership
- For profit - Corporation
- Record Window
- April 12, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Standard health inspection
2 findings
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Sep 16, 2025
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Sep 16, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
3 findings
- F578Honor 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.Level JImmediate jeopardyCorrected Apr 2, 2025
- F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level ENo actual harm, potential for moreCorrected Apr 2, 2025
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 2, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
14 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Dec 12, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Dec 12, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 12, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level FNo actual harm, potential for moreCorrected Dec 12, 2024
- F610Respond appropriately to all alleged violations.Level FNo actual harm, potential for moreCorrected Dec 12, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Dec 12, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F620Not 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.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
- F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
9 findings
The same visit included a complaint investigation.
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Jul 19, 2024
- F625Notify 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.Level ENo actual harm, potential for moreCorrected Jul 19, 2024
- F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
Enforcement Action
Civil money penalty, $103,883 imposed November 4, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 20, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed November 4, 2024. Status: Closed, December 12, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 20, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $16,985 imposed March 12, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 20, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
5 findings
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Mar 26, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 26, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 26, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 26, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 26, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
3 findings
- F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Nov 8, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 8, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Nov 8, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
6 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 10, 2023
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected May 10, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 10, 2023
- F758Implement 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.Level DNo actual harm, potential for moreCorrected May 10, 2023
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected May 10, 2023
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 10, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Telling Families About Changes, Cited in Two Inspections
Inspectors cited F580 in February 2024 and November 2024. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F580 across all 7 inspections, oldest to newest - 2
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in October 2023 and November 2024. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F609 across all 7 inspections, oldest to newest - 3
Investigating Alleged Violations, Cited in Two Inspections
Inspectors cited F610 in October 2023 and November 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F610 across all 7 inspections, oldest to newest - 4
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in February 2024 and November 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F677 across all 7 inspections, oldest to newest - 5
Citation F678, Cited in Two Inspections
Inspectors cited F678 in June 2024 and March 2025. The agency describes it this way: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F678 across all 7 inspections, oldest to newest - 6
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in June 2024 and November 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F689 across all 7 inspections, oldest to newest - 7
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in April 2023 and February 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F755 across all 7 inspections, oldest to newest - 8
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in April 2023 and August 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F759 across all 7 inspections, oldest to newest - 9
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in June 2024 and August 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F761 across all 7 inspections, oldest to newest - 10
Medical Records, Cited in Two Inspections
Inspectors cited F842 in October 2023 and February 2024. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232424242525F842 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in two inspections, most seriously at level D.
- 02
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level F.
- 03
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level F.
- 04
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
- 05
What changed after F678 was cited, and how do you check it now?
Citation F678: cited in two inspections, most seriously at level E.
- 06
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level G.
- 07
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
- 08
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level D.
- 09
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
- 10
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in November 2024.
- 12
What led to the 2025 fine, and has it been paid?
A $16,985 civil money penalty was imposed March 12, 2025. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Apr 12, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Oct 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Feb 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jun 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Nov 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Mar 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Aug 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 525702
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowApril 12, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before April 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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