Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Lake Health And Rehab Center during CMS and state inspections, most recent first.
Failure to Report Alleged Abuse/Neglect: A resident with pelvic fractures, osteoporosis, dementia, and moderate cognitive impairment filed a grievance alleging staff ignored pain complaints, failed to apply cream, and discouraged use of the call light. The grievance also included a CNA’s statement that the resident would not be put to bed because of frequent call light use and short staffing. The facility completed an internal investigation and determined there was no abuse or neglect, but did not report the allegation to the SA.
A resident with two biliary drains had conflicting hospital discharge instructions and incomplete facility transcription of orders for flushing, drainage, and dressing changes. The TAR and chart did not clearly distinguish the two drains, the post-procedure instructions about attaching a bag and later capping the drain were not clarified or implemented, and staff interviews confirmed confusion about which drain care orders were in effect.
The facility failed to update care plans for residents after falls and for residents using specialty air mattresses. One resident with dementia and high fall risk had a post-fall Posey grip intervention documented but not added to the care plan, and another resident with epilepsy and muscle weakness had a fall with head and back impact but no new care plan intervention. Several residents had specialty air mattresses in use, but the mattresses were not reflected in the care plan or Kardex, and staff did not consistently document shift checks of the mattress function.
Multiple residents with cognitive impairments reported verbal abuse and neglect by CNAs, including being left without assistance and exposed to inappropriate language. The facility did not thoroughly investigate these allegations or provide timely staff education to prevent recurrence, and staff confirmed that abuse/neglect training had not been recently updated.
Two residents reported incidents of neglect and inappropriate staff behavior, including being left without assistance and being told to perform tasks they could not complete. Despite these allegations and supporting documentation, the facility did not report the incidents to the State Agency as required by policy.
The facility did not adequately investigate an allegation of resident-to-resident abuse after a cognitively impaired resident reported being threatened by their roommate. Only the reporting resident was interviewed, and other involved or cognitively intact residents were not included in the investigation, resulting in an incomplete response to the abuse allegation.
A resident's medical record lacked documentation of toileting assistance during a shift when the resident, who required frequent toileting due to fall risk, experienced an unwitnessed fall resulting in injury. Nursing staff confirmed that toileting was provided but not recorded in the EMR, contrary to facility policy requiring at least once-per-shift documentation.
The facility failed to ensure sanitary food storage and preparation, affecting all 59 residents. Surveyors found multiple undated and unlabeled food items, improper sanitizing practices, and inadequate dishwasher temperatures. Staff used incorrect test strips for sanitizing solutions and did not maintain logs. Additionally, a dietary aide was observed handling clean dishes without proper hand hygiene. The Director of Culinary Operations confirmed the lapses in following FDA Food Code and facility policies.
A resident was transferred to the hospital due to a fall and elbow fracture, but the facility failed to notify the Ombudsman as required by their policy. The Social Worker indicated that the facility only notifies the Ombudsman if a resident remains in the hospital overnight or is discharged, leading to the omission of this transfer from the monthly notification list.
Two residents requiring assistance with ADLs experienced significant delays in call light responses, with one resident waiting over 30 minutes to an hour, leading to incontinence. Staff interviews revealed that the facility's goal was to respond within 20 minutes, but delays were attributed to PPE protocols and staff forgetting to deactivate call lights.
Two residents in a facility were not monitored for adverse reactions to high-risk medications, including opioids, diuretics, and anticonvulsants. Despite the facility's policy requiring monitoring, the care plans for these residents lacked necessary interventions. The Nurse Manager confirmed the deficiency, and the DON cited challenges with a new electronic health record system.
The facility failed to administer updated COVID-19 vaccines to two residents, despite having signed consent forms from their POAHC. One resident had moderate cognitive impairment and the other had intact cognition, with both having received their last COVID-19 vaccines in early 2021. The Infection Preventionist confirmed the oversight, and the facility was in the process of implementing a new tracking system for vaccinations.
Failure to Report Alleged Abuse/Neglect
Penalty
Summary
The facility did not ensure allegations of abuse or neglect were reported to the State Agency for a resident who had filed a grievance with the facility. The resident was admitted for rehab after a fall and had diagnoses including multiple pelvic fractures, a sacral fracture, spinal stenosis, age-related osteoporosis with a current pathological fracture, cognitive communication deficit, and unspecified dementia. The resident’s MDS assessment showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The grievance, filed by the resident and family, alleged that during the night the resident called out in pain and someone closed the door without checking on them, that staff had not applied cream for the prior 3 days and the resident’s pain worsened, and that a CNA told the family the resident would not be put to bed because the resident would keep the CNA up all night with the call light. The grievance also stated staff told the resident not to use the call light so much because it would wear out, which upset the resident and made them fearful to use it. The facility completed its initial investigation within 24 hours and determined there was no abuse or neglect, but it did not report the allegation to the SA; survey review also noted some investigatory interviews were completed after the 24-hour window and the date of resolution was listed as 4/1/26.
Incomplete and Conflicting Orders for Biliary Drain Care
Penalty
Summary
The facility did not ensure care was provided in accordance with physician orders for a resident with biliary acute pancreatitis and two abdominal drains. The resident had intact cognition with a BIMS score of 15 out of 15 and was admitted with a right upper quadrant drain and a left internal/external biliary drain. The hospital discharge summary included instructions for both drains to be flushed with 10 ml of normal saline twice daily, and also contained discharge instructions that stated to flush the biliary drain once daily, creating conflicting directions. The resident’s medical record and TAR did not accurately reflect the discharge instructions, and the orders were not clarified or implemented as written. The TAR showed multiple changes to drain-related orders over time, including orders for flushing, documenting output, and dressing changes, but the record did not consistently identify both drains or clearly distinguish which drain was to be flushed, drained, or capped. A progress note on 4/12/26 first indicated that one drain was capped and the left drain had a bag attached, yet there was no documentation that the facility contacted the discharging provider to clarify the discharge instructions that both drains were attached to drainage. The record also showed gaps and inconsistencies in dressing-change orders, with progress notes documenting dressing changes during periods when the TAR did not contain corresponding orders. After a 5/4/26 drain procedure, an after visit summary stated the biliary tube was attached to a bag and the physician would tell the resident when to remove the bag and cap the drain. Additional pages in the record included a nursing note stating the right drain was removed and the center biliary drain was replaced with a drainage bag attached. However, the after visit summary was not transcribed into the resident’s medical record, was not clarified, and was not implemented. Staff interviews confirmed confusion about the orders, including uncertainty about whether one or both drains should be flushed, whether the drain should remain attached to a bag, and whether the capped drain should have been flushed. The resident later reported communication issues with the hospital instructions and stated the drain had continued to be emptied multiple times per day even though it was supposed to have been capped after the procedure.
Failure to Update Care Plans After Falls and Specialty Mattress Use
Penalty
Summary
The facility did not review and revise the comprehensive plan of care for 5 of 8 sampled residents after changes in condition or new interventions were identified. The report cited failures to update care plans for residents after falls and for residents using specialty air mattresses, despite facility policies requiring immediate documentation and communication of new interventions and care plan updates by the Nurse Manager. The comprehensive care plan was also not reflected in the Kardex or EHR for several residents with specialty mattresses. R73, who had diagnoses including spinal stenosis, age-related osteoporosis with current pathological fracture, cognitive communication deficit, and unspecified dementia, had a BIMS score of 9 and was at high risk for falls after a recent fall with pubic rami and right sacral fractures. After R73 fell from a wheelchair on 4/4/26, staff documented immediate interventions including a Posey grip on top of the wheelchair cushion, reminders to lock wheelchair brakes, and to use the call light, but the care plan did not include the Posey grip intervention. RN-F confirmed the intervention was not added to the care plan. R61, who had rheumatoid arthritis, epilepsy, cognitive communication deficit, and muscle weakness, had an unwitnessed fall after sliding from a recliner and striking the head and back. The resident was found on the floor, screamed in pain, and was sent to the ER, where the report noted normal pain magnified after the fall. DON-B confirmed no intervention was added to R61's care plan after the fall. R56, who was on hospice and had a chronic right foot wound and a new stage 2 coccyx pressure injury, had a specialty air mattress observed in use, but the mattress was not reflected on the care plan or Kardex and staff did not document checking its function each shift. R21 and R68 also had specialty air mattresses that were not reflected on their plans of care or Kardex, and DON-B confirmed specialty air mattresses should be reflected in the medical record.
Failure to Investigate and Address Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and respond to multiple allegations of abuse and neglect involving four residents. One resident reported that a CNA used inappropriate language during care and requested not to be cared for by that CNA in the future. During the investigation, another staff member reported that the same CNA made an inappropriate comment to a second resident. Both residents had moderately impaired cognition and activated Powers of Attorney for Healthcare. The investigation did not document that staff education was provided to prevent further verbal abuse, as required by facility policy. Additionally, grievances from two other residents alleged that a different CNA neglected their care by asking them to perform tasks they were unable to complete and leaving them without assistance. One resident described being left on the toilet without a call light within reach and hearing inappropriate language from staff. Despite these grievances, the only documented staff education occurred a month prior to the incidents, and there was no evidence of further education or competency checks following the allegations. Interviews with staff confirmed that abuse/neglect education had last been provided several months before the incidents.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to ensure that allegations of abuse and neglect were reported to the State Agency (SA) for two residents. One resident, who was cognitively intact and responsible for their own medical decisions, reported being left in the bathroom without a call light for approximately 30 minutes, being asked to perform tasks they could not do independently, and overhearing staff use inappropriate language. The resident also described an incident where a staff member threw a catheter bag across the room and did not provide timely assistance when requested. These concerns were documented in a grievance and confirmed during an interview, but were not reported to the SA as required by facility policy. Another resident, who had moderately impaired cognition and an activated Power of Attorney for Healthcare, reported that a staff member consistently failed to provide requested care, such as moving a garbage can or assisting with clothing and positioning. The resident described feeling that the staff member did not want to help and recounted an incident where they sustained a skin tear while attempting to change their own brief after being told by staff to do so independently. These grievances and statements were reviewed in the resident's medical record and through staff interviews, but the allegations were not reported to the SA. The facility's policy requires immediate review and reporting of incidents that fit the definitions of abuse or neglect to the Division of Quality Assurance/Office of Caregiver Quality. Despite this, the facility did not report the allegations for either resident, with the Nursing Home Administrator stating that the grievances were considered subjective and did not warrant reporting. This inaction resulted in a failure to comply with regulatory requirements for reporting suspected abuse and neglect.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to properly investigate an allegation of resident-to-resident abuse involving two residents. One resident, who was cognitively intact and had a diagnosis of COPD, allegedly made a threatening statement to another resident, who was moderately cognitively impaired and had a diagnosis of major depressive disorder. The incident was reported by a medication aide after the resident receiving medication stated that their roommate had threatened them. The facility's investigation only included an interview with the resident who reported the threat and did not include interviews with other involved or cognitively intact residents, including the alleged perpetrator. The Registered Nurse Manager confirmed that the investigation was incomplete and that other residents should have been interviewed.
Incomplete Medical Record Documentation for Resident Toileting
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurate, and readily accessible, as required by professional standards and facility policy. Specifically, there was no documentation in the electronic medical record (EMR) regarding toileting for the resident from the evening through the following morning, despite the resident's need for frequent toileting assistance due to a tendency to attempt getting up without calling for help. The resident experienced an unwitnessed fall during this period, resulting in a skin tear and head injury, and required evaluation in the emergency department due to being on anticoagulation therapy. Interviews with nursing staff revealed that the responsible RN provided toileting assistance twice during the shift in question but failed to document these interventions in the CNA task section of the medical record. Facility policy required documentation of care provided and resident response, with an expectation of at least once-per-shift documentation for toileting. The DON confirmed that staff should offer toileting every two to two and a half hours and document at least once per shift unless something unusual occurs. The lack of documentation meant that the medical record was incomplete and not in accordance with accepted standards.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 59 residents. During a kitchen tour, surveyors observed multiple open, undated, unlabeled, and expired items in the dry storage area, coolers, and freezer. The Director of Culinary Operations (DCO) confirmed that the facility follows the FDA Food Code, which requires proper labeling and dating of food items. However, numerous items, including ground pretzels, bulk flour, oatmeal, prepared potatoes, and various salads, were found without use-by dates. The DCO was unsure of the facility's policy regarding bulk items and could not confirm when they were opened. The facility also failed to maintain proper sanitizing practices. The surveyor found that the facility did not have sanitization testing logs for the 3-compartment sink and sanitizing buckets. Staff were using incorrect test strips for the sanitizing solution and were not aware of the need to test the temperature of the solution. The Assistant Director of Dining (ADD) confirmed that the facility had the appropriate test strips but needed to review the process with kitchen staff. Additionally, the dishwasher temperatures did not reach the appropriate levels for effective sanitization, and the facility did not keep sensor tags to verify if the required temperatures were achieved. Furthermore, the facility did not maintain sanitary dishwashing practices. During the kitchen tour, a dietary aide was observed handling clean dishes without changing gloves or performing hand hygiene after handling soiled equipment. The aide confirmed the lapse in hand hygiene, acknowledging the mistake. The DCO and ADD confirmed that staff are trained on appropriate dishwashing techniques, including proper hand hygiene and infection control practices, but these were not followed during the surveyor's observation.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a hospital transfer for a resident, identified as R52, which constitutes a deficiency. R52 was transferred to the hospital on December 31, 2024, due to a fall resulting in an elbow fracture. Although R52 was provided with a written transfer notice, the facility did not inform the Ombudsman about this transfer. The facility's policy requires that the Social Services Director or designee provide copies of notices for emergency transfers to the Ombudsman, which can be sent on a monthly basis. However, R52 was not included in the December 2024 Ombudsman notifications. During an interview, the Social Worker indicated that the facility does not notify the Ombudsman if a resident transfers to the hospital and returns the same day. The notification is only made if the resident remains in the hospital overnight or is discharged. This practice led to the omission of R52's transfer from the monthly notification list, despite the facility's policy requiring such notifications. The surveyor's review of R52's medical record and the facility's notification list confirmed this oversight.
Delayed Response to Call Lights for Residents Requiring ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance for activities of daily living (ADLs) to two residents, R3 and R12, who required help. R3, with intact cognition, reported waiting over 30 minutes to an hour for assistance to use the bathroom, leading to incontinence. A review of R3's call light activity from January 1 to February 19, 2025, showed 117 instances where response times exceeded 20 minutes, with some extending up to 120 minutes. R12, with moderately impaired cognition, also experienced delays, waiting over 20 to 30 minutes for assistance, with a call light activity report indicating 55 instances of delayed responses over the same period. Interviews with staff, including a Registered Nurse Supervisor and a Certified Nursing Assistant, revealed that the facility's goal was to respond to call lights within 20 minutes. However, staff acknowledged that response times were often longer, partly due to the need to don and doff personal protective equipment for COVID-19 precautions. The Nursing Home Administrator also noted that some staff forget to deactivate call lights after responding. These delays in responding to call lights resulted in unmet needs for the residents, impacting their quality of life.
Failure to Monitor Adverse Reactions to High-Risk Medications
Penalty
Summary
The facility failed to ensure that two residents, R18 and R46, were monitored for adverse reactions to high-risk medications, specifically opioids, diuretics, and anticonvulsants. R18, who had severe cognitive impairment and was receiving hospice services, was prescribed fentanyl and oxycodone for pain management. However, R18's care plan lacked interventions for monitoring potential adverse reactions such as sedation, dizziness, nausea, vomiting, constipation, and respiratory depression. Similarly, R46, who had intact cognition and was also receiving hospice services, was prescribed morphine, oxycodone, spironolactone, and gabapentin. R46's care plan did not include monitoring for adverse reactions to these medications, which could include sedation, dizziness, nausea, vomiting, constipation, respiratory depression, dehydration, headache, fatigue, tremors, rash, blurred vision, and weight gain. The facility's policy on high-risk medications requires that care plans alert staff to monitor for adverse consequences and include interventions to minimize risks. Despite this policy, the care plans for R18 and R46 did not meet these requirements. During interviews, the Nurse Manager confirmed the absence of monitoring interventions in the care plans, and the Director of Nursing acknowledged that staff should monitor for adverse reactions but cited challenges with a new electronic health record system. The Director of Nursing was also unsure about the specifics of the facility's policy on high-risk medication monitoring.
Failure to Administer Updated COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to ensure that two residents, R52 and R18, received an updated COVID-19 vaccine despite having signed consent forms from their activated Power of Attorney for Healthcare (POAHC). R52, who was admitted with diagnoses including Alzheimer's disease, congestive heart failure, and cerebral vascular accident, had a moderate cognitive impairment with a BIMS score of 9 out of 15. R52's medical record showed that the last COVID-19 vaccine was administered on January 12, 2021, and there was no indication of an offer or administration of an updated vaccine. Similarly, R18, who had diagnoses of dementia, diabetes, and cerebral vascular accident, had intact cognition with a BIMS score of 13 out of 15. R18's medical record indicated the last COVID-19 vaccine was administered on March 12, 2021, with no record of an updated vaccine being offered or administered. The surveyor's interview with the Infection Preventionist (IP)-D revealed that the facility had sent COVID-19 vaccination consent forms to the POAHC of both residents, which were signed and dated in late 2024. Despite this, IP-D confirmed that neither resident received the updated COVID-19 vaccines. The facility was in the process of implementing a new tracking system to monitor when residents' vaccines are due or have been administered, but this system was not yet in place at the time of 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 West Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion At Glacier Valley | 6 mi | ★★★★★ | 16 | 0 |
| Samaritan Nursing And Rehab | 6.6 mi | ★★★★★ | 44 | 3 |
| Lasata Care Center | 8.2 mi | ★★★★★ | 8 | 0 |
| Cedarburg Health Services | 8.2 mi | ★★★★★ | 0 | 0 |
| Complete Care At Germantown | 11.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.