Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Williams Bay Health Services during CMS and state inspections, most recent first.
A resident with MS and vision loss, who was cognitively intact, experienced an unwitnessed fall while transferring from the toilet in a private bathroom that lacked adequate support on the left side of the toilet. The resident reported using a right-side grab bar that caused shoulder pain and stated there was no left-side bar after a previously used left-arm support device was removed for being wobbly. Observation showed the bathroom had only a right-side grab bar and a non-skid strip placed too far from where the resident’s feet would rest while seated. A CNA stated the resident was supposed to call for assistance with transfers but was found on the floor between the toilet and sink, and the DON confirmed that a commode with handles had been removed and replaced with a raised toilet seat without further discussion of adding left-side support.
The facility failed to provide adequate supervision and interventions to prevent accidents for two residents. One resident sustained injuries during transfers due to improper handling and environmental hazards, such as exposed metal on a bed frame. Despite the care plan requiring specific assistive devices, staff did not consistently use them, leading to further injury. Another resident did not receive quarterly smoking assessments as required, potentially compromising their safety. These deficiencies highlight lapses in adherence to facility policies and care plans.
The facility failed to maintain an effective infection control program by inaccurately calculating infection rates and not adhering to hand hygiene policies during wound care. An LPN admitted to not calculating individual infection rates, complicating trend analysis. Additionally, an RN did not follow hand hygiene protocols while treating a resident's pressure injuries, as confirmed by the DON.
A resident was injured twice during transfers due to missing plastic caps on the metal bed frame, exposing sharp edges. The facility failed to conduct regular inspections, leading to the resident's leg being cut and an existing wound reopening. An audit revealed numerous beds with similar deficiencies, highlighting the facility's inadequate maintenance practices.
A resident with chronic pain syndrome experienced inadequate pain management at the facility. Despite severe pain reports, the facility failed to administer as needed pain medication consistently and did not offer sufficient non-pharmacological interventions. The resident's pain was not effectively managed, and staff did not collaborate with the healthcare team to adjust the pain management plan in a timely manner.
Failure to Provide Adequate Toilet Transfer Supports and Safe Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s bathroom environment was free from accident hazards and that adequate supports were provided to prevent accidents during toilet transfers. The resident was admitted with multiple sclerosis and vision loss, and the admission MDS showed she was cognitively intact with no falls since admission. On the date of the incident, progress notes documented that the resident was found in a private bathroom sitting on her buttocks between the toilet and sink, stating she had been getting off the toilet, lost her balance, and fell, striking her left shoulder on the sink. A subsequent note indicated the fall was unwitnessed and that the resident, who was on Eliquis, was sent to the hospital after reporting she had hit her head. During interviews, a CNA confirmed the resident was expected to call for assistance with transfers, but the resident was found on the floor when the CNA entered with a lunch tray. The resident reported that in the bathroom where the fall occurred, there was only one grab bar on the right side of the toilet, which she used but which caused shoulder pain, and there was no bar on the left side to support her left arm. She also stated she is blind and has leg weakness due to MS. Observation of the prior bathroom showed a non-skid strip on the floor in front of the toilet, but it was placed too far from where her feet would be while seated. In the current bathroom, there was a toilet riser and a right-side grab bar, but no left-side support, and the resident reported that a prior left-arm support device had been removed because its legs were wobbly, leaving her without left-side support. The DON confirmed that a commode with handles over the toilet had been removed due to being wobbly and replaced with a raised toilet seat, and acknowledged there had been no discussion about adding left-side support after that change.
Inadequate Supervision and Environmental Hazards Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent accidents for two residents, R26 and R29. R26 sustained injuries during transfers on multiple occasions due to improper handling and environmental hazards. On one occasion, R26's leg was injured due to a missing cap on the bed frame, exposing sharp metal edges. Despite the facility's policy on safe resident handling, staff did not consistently use the required assistive devices, such as a 2-wheel walker and gait belt, during transfers. This lack of adherence to the care plan and failure to address environmental hazards contributed to R26's injuries. R26, who is cognitively intact and has impairments in bilateral lower extremities, experienced significant pain and skin tears due to these incidents. The facility's documentation revealed that R26's care plan required assistance from two staff members using a walker and gait belt for transfers. However, observations showed that staff did not follow these guidelines, leading to further injury. Additionally, the facility's audits identified missing plastic pieces on bed frames, which posed a risk to residents, including R26. For R29, the facility failed to conduct quarterly smoking assessments as required by their policy. R29, who is cognitively intact and has significant physical impairments, was determined to be independent with smoking. However, the last smoking assessment was completed several months prior, and the facility did not provide a valid reason for the oversight. This lack of regular assessment could have compromised R29's safety, as the facility's policy mandates regular evaluations to determine the need for supervision during smoking activities.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by inaccurate calculation of total infection rates and individual infection types. The Licensed Practical Nurse (LPN) in charge of the infection control program admitted to not calculating individual rates of infection and including infections from previous months and chronic infections in the monthly totals. This practice made it difficult to analyze data for trends or increases in infection rates. The facility's infection surveillance policy required monthly data capturing and reporting to monitor trends, but the facility did not adhere to this policy, as evidenced by the review of monthly infection rate surveillance summary reports. Additionally, a deficiency was observed in the hand hygiene practices during wound care for a resident with unstageable pressure injuries. The Registered Nurse (RN) performing the wound care did not follow the facility's hand hygiene policy, which required hand hygiene after handling contaminated objects and before and after applying personal protective equipment. The RN failed to perform hand hygiene after removing soiled gloves and before donning new gloves during the treatment of the resident's wounds. This was confirmed by the Director of Nursing (DON), who observed the procedure and acknowledged the deviation from the facility's policy.
Failure to Inspect and Maintain Bed Frames Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure proper inspection and maintenance of resident beds, leading to injuries for a resident during transfers. On two separate occasions, the resident was injured due to missing plastic caps on the metal bed frame, which exposed sharp edges. The first incident occurred when the resident hit their leg on the bed frame, resulting in a deep skin tear that required emergency medical attention. The facility's documentation identified the missing cap as the root cause of the injury, and a temporary fix was applied by using a part from another bed. Despite the initial incident, a second injury occurred when the resident's existing wound reopened after making contact with the metal bed frame during a transfer. This incident highlighted the ongoing issue of missing caps, as an audit revealed numerous beds with similar deficiencies. The facility's maintenance director admitted that the inspection process did not initially include checking for missing end caps, and it was only after the incidents that this became a focus. The facility's failure to conduct regular and thorough inspections of the beds contributed to the resident's injuries.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R26, who was admitted with diagnoses including Polyneuropathy, anxiety, and Chronic Pain Syndrome. Despite being on a scheduled pain medication regimen, R26 experienced frequent and severe pain, which was not effectively managed. The facility did not administer as needed pain medication on certain dates and failed to offer non-pharmacological interventions consistently. R26 reported significant pain levels, which interfered with daily activities and mobility, yet the facility did not adequately address these complaints or adjust the pain management plan in a timely manner. The facility's policy on pain management was not followed, as staff did not incorporate non-pharmacological interventions into R26's care plan, nor did they notify the healthcare practitioner when pain medications were ineffective. R26 expressed to the surveyor that the pain was severe, reaching a 10 out of 10 on the pain scale, and described it as stabbing pain. Despite these reports, the facility's response was inadequate, with limited interventions such as elevating the leg and delayed implementation of an ice pack. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed a lack of collaboration with the healthcare team to adjust R26's pain management plan. The facility's documentation showed that pain medications were often ineffective, yet there was no evidence of timely communication with the physician or implementation of alternative pain management strategies. The deficiency was highlighted when the surveyor noted that new interventions were only initiated after concerns were raised during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Williams Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delavan Health Services | 5.6 mi | — | 0 | 0 |
| Geneva Lake Manor | 6.2 mi | — | 9 | 1 |
| Golden Years Of Lake Geneva | 7 mi | — | 0 | 0 |
| Holton Manor | 7.1 mi | — | 0 | 0 |
| Lakeland Health Care Ctr | 7.1 mi | — | 5 | 0 |
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