Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edenbrook Lakeside during CMS and state inspections, most recent first.
The facility failed to consistently designate a licensed nurse as charge nurse on each shift and did not staff according to its own facility assessment and stated minimum ratios, especially on weekends. Nursing schedules reviewed over a 30‑day period did not clearly identify a charge nurse for every tour of duty, and leadership acknowledged reliance on informal knowledge and an on‑call rotation rather than documented assignment. The facility assessment outlined higher nurse and CNA staffing levels by floor and shift, based on census and acuity, than those actually scheduled, and surveyor review showed reduced weekend staffing over several months, contributing to a pattern of excessively low weekend staffing affecting all residents.
A respiratory therapist with an expired and non-renewed license continued to work in a respiratory therapist capacity, monitoring and providing care for an average of 14 residents with tracheostomies. The facility lacked a credentialing policy for respiratory therapists, and responsibility for tracking licenses had been assigned to a former HR manager. The NHA was unaware of the license lapse until shortly before the survey, while the SDD reported using tracking tools but confirmed that the departed HR manager had been responsible for monitoring this therapist’s license status.
A resident with multiple medical conditions and an identified ADL self-care deficit was care planned to receive one-person assistance with bathing, dressing, and personal hygiene, with showers scheduled twice weekly. Over several days, the resident was observed with disheveled, later matted, hair and wearing the same clothing, while review of records showed no showers provided since admission and no documentation of any refusals in the EMR, despite facility policy requiring documentation and re-approach of refusals. Staff interviews revealed uncertainty about whether the resident had refused showers and an ADON assertion that the resident should have bathed at home during a pass, while the resident reported not having time to shower at home and expressed a desire for a shower, demonstrating that necessary ADL services for bathing and grooming were not provided or documented as required.
A resident was transferred to the hospital without being provided all required transfer notice information, including the reason for transfer, appeal rights, and correct Ombudsman contact details. The forms used by the facility, created and revised by the corporate office, did not meet regulatory requirements, and staff confirmed the missing information.
A resident was denied immediate readmission after hospitalization because facility staff required additional insurance paperwork, despite the resident's Medicaid coverage and no change in clinical status. Miscommunication among staff led to the resident being sent back to the hospital, even though there was no regulatory reason to deny readmission.
A resident with severe cognitive impairment and multiple medical conditions did not receive post-fall assessments as required by the facility's policy. The policy mandates documentation every shift for 72 hours post-fall, but assessments were missing for several shifts following two separate falls. The Director of Nursing confirmed the deficiency during an interview.
A facility failed to maintain ongoing communication with a dialysis center for a resident requiring dialysis, resulting in a lack of documented communication for 12 appointments. The facility's policy mandates reviewing post-dialysis communication, which was not followed. The issue was attributed to the dialysis center not returning the communication binder, and attempts to retrieve information via fax were made. The deficiency was noted by a surveyor and communicated to the facility's administration.
Two residents in the facility did not have comprehensive care plans addressing their specific needs. One resident with a foley catheter lacked a care plan for catheter management, while another resident's care plan inaccurately documented toileting needs despite frequent incontinence. The facility's failure to update care plans reflects a lapse in the interdisciplinary team process and communication.
A resident receiving medications through a G tube did not receive care meeting professional standards when an LPN administered medications without verifying tube placement. The facility's policy requires checking the tube's placement before administering medications, but this procedure was not followed. The Director of Nursing acknowledged the concern, confirming the policy requirement.
A facility's medication error rate was 41.67% due to an LPN failing to flush a resident's G tube with water before and after administering 15 medications, contrary to the facility's policy. The DON acknowledged the policy violation.
A resident with multiple diagnoses did not receive several physician-ordered medications upon admission due to unavailability, and the physician was not notified. The DON confirmed the lapse, which was against facility policy.
A resident did not receive insulin before meals as ordered by the physician. The insulin was administered after meals on multiple occasions, contrary to the facility's policy and the physician's orders. The RN delayed the administration due to concerns about the resident not eating and other issues on the floor. The DON confirmed the discrepancy.
Failure to Designate Charge Nurses and Maintain Weekend Staffing per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and to designate a licensed nurse as charge nurse for each tour of duty, as required to meet residents’ needs. Review of 30 days of nursing schedules showed that the schedules did not consistently identify who the charge nurse was for each shift, and sometimes listed a charge nurse only for the evening shift. During an interview, the Staff Development Director stated that during the day the DON, assistant DONs, or infection preventionist are in the building and that staff "know" who the evening and night charge nurses are, and referenced an on‑call rotation. However, the facility did not provide documentation or explanation showing that a licensed charge nurse was clearly designated on each shift, and the Nursing Home Administrator acknowledged the concern when interviewed about the schedules. The deficiency also includes the facility’s failure to staff according to its own facility assessment and stated minimum staffing ratios, particularly on weekends. The facility assessment, last reviewed in November 2025, specified licensed nurse‑to‑resident and CNA‑to‑resident ratios and detailed expected staffing by floor and shift, with staffing to be based on census and acuity. In contrast, the Staff Development Director described lower minimum staffing levels actually used on the schedule, and surveyor review of October 2025 schedules showed reduced staffing on weekends compared to both the facility assessment and the Director’s stated minimum ratios. The facility triggered for excessively low weekend staffing from October through December 2025, and both the Staff Development Director and the Nursing Home Administrator acknowledged staffing challenges during that period, with no additional information provided to reconcile the discrepancy between assessed needs and actual staffing. This deficient practice had the potential to affect all 98 residents in the facility.
Unlicensed Respiratory Therapist Provided Tracheostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized respiratory therapy services were provided by qualified, licensed personnel. The facility had an average of 10–18 residents receiving tracheostomy care, with an average census of 14 residents with tracheostomies while Respiratory Therapist (RT)-L was employed. RT-L was hired with a respiratory therapist license that later expired, and RT-L continued to work in a respiratory therapist capacity in the facility after the license expiration date. Review of the Department of Human Services (DHS) online license look-up confirmed that RT-L’s license had expired and that renewal had been denied. Time clock records verified that RT-L continued to work in the role of a respiratory therapist after the license expiration and up until the last recorded work date. The facility did not have a policy for credentialing respiratory therapists, and responsibility for monitoring licenses had been assigned to a human resources manager who was no longer employed at the facility. The Nursing Home Administrator (NHA) reported being unaware that RT-L’s license had lapsed until informed shortly before the survey and acknowledged concern about the situation. The Staff Development Director (SDD) described using a checklist and spreadsheet to track employee licenses and certifications but indicated that the former human resources manager was responsible for monitoring RT-L’s license status. Another respiratory therapist (RT-N) stated that respiratory therapists in the facility are primarily responsible for monitoring all residents with tracheostomies, confirming that RT-L was functioning in this capacity while unlicensed.
Failure to Provide and Document Assisted Bathing and Hygiene for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically bathing, grooming, and personal hygiene, to a resident who required assistance. Facility policy on ADLs, revised 2/25/2025, states that residents will receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including assistance with bathing/showering, personal hygiene, and dressing, individualized to resident needs and preferences, with refusals reported to a nurse, re-approached, and documented in the EMR. The resident’s comprehensive care plan dated 3/18/26 identified an ADL self-care performance deficit related to multiple medical conditions, with interventions specifying one-person assist for bathing/showering, dressing, and personal hygiene/oral care, and assistance with clothing selection and dressing. Despite these care plan directives, the resident was repeatedly observed over multiple days with very disheveled hair and wearing the same long sleeve blue shirt and dark gray pants, with hair later noted to be matted in some areas. The CNA assignment book showed the resident was scheduled for showers twice weekly, yet review of shower documentation revealed the resident had not received any showers since admission. The resident reported possibly having had only one shower since admission, was aware that their hair was “wild,” and stated they did not have other clothes to change into. There was no documentation in the EMR of any shower refusals by the resident. Interviews with staff further demonstrated a lack of adherence to policy and care plan. One CNA described the process for re-approaching residents who refuse showers but did not confirm refusals for this resident, stating they had not worked or been assigned to the resident on shower days. The ADON initially stated the resident had refused all showers and that such refusals should be documented in the EMR, but upon review with the surveyor, acknowledged there was no documentation of refusals. The ADON also stated that the resident should have taken a shower at home during a pass, and later questioned the resident, who reported not having time to shower at home and expressed a desire for a shower. These observations and interviews show that the resident did not receive the planned and required assistance with bathing, grooming, and personal hygiene, and that staff did not document any refusals as required by facility policy.
Failure to Provide Complete Transfer Notice Information
Penalty
Summary
The facility failed to provide all required transfer notice information for a resident who was transferred to the hospital. Specifically, the documentation for the resident's transfer did not include the reason for the transfer, information about appeal rights, the correct contact information for the Ombudsman, or the correct email address for the Regional Field Operations Director for the Division of Quality Assurance. The facility's policy requires that residents and their representatives receive written notice of transfer or discharge, including specific information about the transfer, appeal rights, and contact details for relevant advocacy entities. Review of the resident's medical record showed that the Bed-Hold Agreement - Transfer Notice forms used on two separate occasions were missing required elements. Interviews with facility staff revealed that the forms were created and revised by the corporate office, but even the most recent versions did not meet regulatory requirements. The staff responsible for maintaining these forms confirmed that the necessary information was not included in the documents provided to the resident and their representative.
Resident Denied Readmission Due to Administrative Paperwork Delay
Penalty
Summary
The facility failed to permit a resident to return to the facility immediately following hospitalization, despite there being no clinical or regulatory reason to deny readmission. The resident, who was covered by a managed Medicaid plan and had a legal guardian, was transferred to the hospital and, upon discharge, was ready to return to the facility. The facility's own policy states that a resident whose hospitalization exceeds the bed-hold period should be readmitted if they require the facility's services and are eligible for Medicaid or Medicare. However, when the hospital attempted to discharge the resident back to the facility, the facility refused readmission, citing incomplete insurance paperwork, specifically the absence of a Medicare denial form, even though the resident's Medicaid plan would continue to cover the stay and such a denial was not required. Interviews with facility staff revealed confusion and miscommunication regarding the necessary paperwork for readmission. The Director of Marketing confirmed that all authorizations were believed to be in place, but the Corporate Admissions staff insisted on having a Medicare denial form before readmitting the resident. The Nursing Home Administrator acknowledged misunderstanding the situation and did not allow the resident to return, resulting in the resident being sent back to the hospital. The surveyor confirmed there was no regulatory reason for the denial, and the facility's actions were based solely on internal administrative requirements rather than the resident's clinical status or eligibility.
Failure to Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that a resident received post-fall assessments as per the facility's policy, which requires documentation of the resident's condition every shift for 72 hours following a fall. This deficiency was identified for one resident who experienced falls on two separate occasions. The facility's policy mandates that staff document relevant clinical findings such as vital signs, pain, swelling, bruising, and changes in function or cognitive status after a fall. However, the surveyor found that for the falls occurring on June 29 and August 30, several shifts lacked the required assessments, with five shifts missing documentation for each fall. The resident involved had a history of significant medical conditions, including nontraumatic intracerebral hemorrhage, hydrocephalus, encephalopathy, abnormalities of gait and mobility, cognitive communication deficit, and restless leg syndrome. The resident was also noted to be severely cognitively impaired with impairments to one side of their upper and lower extremities. Despite these conditions, the facility did not complete the necessary post-fall assessments, as confirmed by the Director of Nursing during an interview. The Director acknowledged that the assessments should have been completed as scheduled but admitted that the documentation provided to the surveyor was all that was available.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with a dialysis center for a resident requiring dialysis services, as per professional standards of practice. The resident, who is cognitively intact and has a physician order for dialysis three times a week, had no communication documented between the facility and the dialysis center for 12 scheduled dialysis appointments. The last recorded communication was dated over a month prior to the surveyor's review. The facility's policy requires reviewing communication documents for pertinent information post-dialysis, which was not adhered to in this case. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the issue, attributing it to the dialysis center's failure to return the communication binder. Despite attempts to retrieve the missing information via fax, the facility struggled to maintain up-to-date records. The surveyor highlighted the importance of timely communication as per the Center for Medicare/Medicaid Services memorandum, which emphasizes the need for collaboration between dialysis facilities and nursing homes to ensure effective and safe treatments. The deficiency was communicated to the DON and Nursing Home Administrator during an end-of-day meeting.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, R82 and R31, had individualized comprehensive care plans addressing their specific needs. R82, who was admitted with multiple diagnoses including a fracture, Guillain-Barre syndrome, and diabetes, had a foley catheter inserted due to urinary retention. Despite this significant change in R82's condition, the facility did not develop a comprehensive care plan for the catheter management, as confirmed by the surveyor's review of R82's records and interviews with the Director of Nursing (DON). The DON acknowledged that the care plan should have been initiated when the catheter was inserted, but it was missed in the daily morning meetings where care plans are typically finalized. R31, another resident with diagnoses including metabolic encephalopathy and muscle weakness, was assessed as frequently incontinent of bowel and bladder. However, the care plan in place was not person-centered or comprehensive, as it inaccurately stated that R31 was not toileted, despite the resident's MDS indicating frequent incontinence. The surveyor's interview with R31 revealed that the resident received assistance when needed, contradicting the care plan's documentation. The DON initially believed the care plan was resolved because R31 was thought to be continent, but upon review, it was acknowledged that the care plan was incorrectly resolved. These deficiencies highlight the facility's failure to adhere to its policy of developing individualized, comprehensive care plans based on residents' assessments and needs. The lack of appropriate care plans for R82's catheter management and R31's incontinence care indicates a lapse in the facility's interdisciplinary team process and communication, as care plans were not updated or initiated in response to changes in the residents' conditions.
Failure to Verify G Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident receiving medications through a gastronomy (G) tube received care that met professional standards. On October 24, 2024, a surveyor observed a Licensed Practical Nurse (LPN) administering medications to a resident via a G tube without verifying the tube's placement beforehand. The facility's policy, revised on September 8, 2023, requires that the placement of the feeding tube be verified before administering medications, which includes checking the tube's external length and inspecting gastric aspirate. However, the LPN did not follow this procedure and proceeded to administer 15 crushed medications mixed with water without checking the tube's placement. The resident in question had a physician's order dated March 17, 2023, which mandated that the tube placement be checked before the initiation of formula, medication administration, and flushing, or at least every eight hours. During an interview with the Director of Nursing (DON), the surveyor explained the concern regarding the LPN's failure to check the G tube placement. The DON acknowledged the concern and confirmed that it is the facility's policy to verify tube placement prior to medication administration. No additional information was provided by the facility regarding this incident.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure its medication error rates were not 5 percent or greater, resulting in a medication error rate of 41.67%. On October 24, 2024, a resident identified as R55 was administered 15 medications via a gastronomy (G) tube by an LPN. The LPN did not flush the G tube with water before or after administering the medications, which is a violation of the facility's policy. The facility's policy, revised on September 8, 2023, requires flushing the tube with 30 ml of water before and after medication administration. The physician's order allowed for combining medications during G tube administration with flushes as ordered. The Director of Nursing acknowledged the concern when interviewed by the surveyor, confirming that the facility's policy was not followed.
Failure to Administer Ordered Medications Upon Admission
Penalty
Summary
The facility failed to ensure that a resident received ordered medications upon admission, leading to unmet care and health needs. The resident, who had diagnoses including the presence of a right artificial knee joint, end-stage renal disease, and kidney transplant status, was admitted to the facility in the evening. However, several physician-ordered medications were not administered due to unavailability, and there was no evidence that the physician was notified about the unavailability of these medications. Specifically, Belsomra, Prednisone, Apixaban, and Calcium Acetate were not given as ordered on the evening of admission and the following day. The Director of Nursing (DON) confirmed that the medications were not administered and that there were no progress notes indicating that the physician was notified. Facility policy requires that medications be administered according to physician orders and that the physician be notified if medications are not available or not given. The failure to administer these medications and notify the physician was verified through record reviews, interviews, and facility policy review.
Failure to Administer Insulin Before Meals
Penalty
Summary
The facility failed to administer insulin to one resident in a timely manner, as per the physician's order. The resident's Medication Administration Record (MAR) indicated that insulin was to be administered before meals based on a sliding scale determined by the resident's blood sugar levels. However, the insulin was administered after meals on multiple occasions. The resident reported receiving her insulin injections late, both in the morning and at noon, which was confirmed by the Registered Nurse (RN) who administered the insulin. The RN admitted to delaying the insulin administration due to concerns about the resident not eating and other issues on the floor. The Director of Nursing (DON) confirmed that the insulin was administered after meals, contrary to the physician's orders. The facility's policy on administering medications, which requires adherence to the physician's written orders, was not followed. This failure to administer insulin before meals as ordered had the potential to result in unmet healthcare needs for the resident.
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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 Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Johns On The Lake | 0.3 mi | ★★★★★ | 1 | 0 |
| Milwaukee Catholic Home | 0.4 mi | ★★★★★ | 0 | 0 |
| Eastcastle Pl Bradford Ter Conv Ctr | 0.5 mi | ★★★★★ | 16 | 0 |
| Jewish Home And Care Center | 0.8 mi | ★★★★★ | 22 | 3 |
| Milwaukee Health And Rehab | 3.6 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.