Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Lasata Care Center during CMS and state inspections, most recent first.
Failure to Enforce Mask Use During Influenza Outbreak: During an influenza outbreak on unit 1E, the facility's outbreak plan required all staff to wear masks at all times on the affected unit. However, the DON told surveyors masks were optional unless staff were providing care in an affected resident's room, and surveyors observed staff on the unit without face masks. An LPN and CNA reported they had only recently learned the unit was in outbreak status, while the IP later stated staff had been informed of the outbreak and should have been wearing masks at all times.
A resident’s room contained Aquaphor, medicated menthol powder, and two tubes of DermaPhor, including one labeled for another person, even though there were no active orders for the products and no self-administration or bedside storage approval. The resident had intact cognition, did not want to self-administer meds, and staff confirmed the medications should not have been at the bedside or in the room.
The facility did not report a witnessed resident-to-resident abuse incident to law enforcement. A resident with severe cognitive impairment called another resident ugly and slapped the resident on the arm, and staff separated them, but the DON said the event was not considered abusive because there was no injury and questioned intent to harm. The facility’s abuse policy required reporting physical abuse and any reasonable suspicion of a crime to local law enforcement, yet police were not notified.
The facility inaccurately submitted staffing data to CMS for fiscal Quarter 3 of 2024, reporting zero RN hours despite having appropriate staffing levels. This error was due to new staff in the Business Office and IT positions failing to submit nursing hours correctly. The issue was discovered during a survey, although sufficient staffing was observed, and no concerns were raised by residents or their representatives.
The facility failed to report allegations of abuse and neglect for three residents to the Nursing Home Administrator (NHA) or the State Agency (SA). Despite policies requiring immediate reporting, the allegations were not communicated, leading to a deficiency in handling abuse and neglect reports.
The facility failed to thoroughly investigate allegations of abuse and neglect for three residents. One resident reported a CNA being short and denying face cream, another reported delayed and rude toileting assistance, and a third resident's daughter reported staff being mean and causing distress. The grievance reports lacked thorough investigation details, including resident and witness interviews.
The facility failed to provide a transfer notice to a resident who was hospitalized after sustaining a skin laceration during a transfer. The medical record lacked the required notice, and staff interviews confirmed the oversight.
Failure to Enforce Mask Use During Influenza Outbreak
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. During an influenza outbreak on unit 1E, the facility's Nursing Respiratory Disease Outbreak Plan and Pandemic Outbreak stated that all staff must wear masks at all times while on the isolated/outbreak unit. On 1/5/26, the survey team was informed by the DON that there was an influenza outbreak on unit 1E, but the DON stated masks were optional for staff for their own protection if they were not providing care in an affected resident's room. At 10:48 AM on 1/5/26, the surveyor observed staff on unit 1E without face masks. PPE carts and signs were observed on several residents' doors. Later that day, an LPN stated staff had been informed that unit 1E was in an outbreak, and a CNA stated staff had only been wearing masks on 1W and had just learned that 1E was in an outbreak. On 1/6/26, the DON was unsure when the third resident was diagnosed and did not know when staff were required to wear masks on the unit. On 1/7/26, the IP stated a third resident on unit 1E was confirmed to have influenza on 1/1/26, which indicated a respiratory outbreak, and that staff on unit 1E were informed of the outbreak on 1/1/26 and should have been wearing masks at all times.
Unauthorized Medications Stored in Resident Room Without Orders
Penalty
Summary
The facility did not ensure accurate and safe medication administration for R7 when medications were found stored in the resident’s room without appropriate authorization or active orders. On 1/5/26, surveyors observed Aquaphor, medicated menthol powder, and two tubes of DermaPhor hydrophil petrolatum topical ointment on top of a refrigerator near the entrance to R7’s room. One DermaPhor tube had a pharmacy label for R7, one had a label for another person, and none of the medications had an active physician order; Aquaphor had been discontinued. R7’s record did not show a self-administration assessment or an order to self-administer medication or keep medication at the bedside. R7 had diagnoses including edema, anxiety, skin infection, stage 4 pressure ulcer, paralytic syndrome following cerebral infarction, and severe protein calorie malnutrition, and had a BIMS score of 15 indicating intact cognition. R7 told the surveyor the medications were R7’s, had been there for a long time, and staff had placed them there, but R7 was not aware that another person’s DermaPhor was in the room and asked for it to be removed immediately. The LPN who entered the room confirmed R7 should not have medication at the bedside because R7 was not approved to self-administer medication and that another resident’s medication should not be in the room. The DON confirmed residents may keep medication in their room only if assessed for bedside storage, that medications applied by staff should have active orders, and that medications not belonging to a resident should not be in the resident’s room. R7’s self-administration assessments indicated R7 did not want to self-administer medication, and R7 did not have an order to store medication at the bedside.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility did not ensure an allegation of abuse was reported to local law enforcement for two residents, R12 and R23. On 10/7/25, staff witnessed R23 call R12 ugly and slap R12 on the arm. The facility’s Abuse/Mistreatment Policy stated that physical abuse includes slapping and that any reasonable suspicion of a crime against a resident must be reported to local law enforcement, but law enforcement was not notified of the incident. The report also states the facility did not contact local law enforcement to develop a working agreement for suspected abuse situations. R23 had diagnoses including dementia with mood disturbance and depression, and an MDS assessment dated 11/11/25 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. R12 had diagnoses including traumatic brain injury, Alzheimer’s disease, cerebral vascular accident, and major depression, and an MDS assessment dated 10/7/25 also showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Both residents had activated POAHC for medical decisions. The record review and staff interviews showed the facility viewed the incident as not abusive because there was no injury and questioned whether there was intent to harm, despite acknowledging that slapping another individual is a form of abuse.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the accurate submission of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) for fiscal Quarter 3 of 2024. The Payroll Based Journal (PBJ) data was not submitted correctly, resulting in zero registered nurse (RN) hours being reported, despite the facility having appropriate staffing levels, including RNs, as per their Facility Assessment. This discrepancy was identified during a survey on September 10, 2024, when the surveyor reviewed the PBJ Staffing Data Report and noted issues such as excessively low weekend staffing and lack of licensed nursing coverage 24 hours a day. Interviews with facility staff revealed that the Business Office Manager (BOM) and Information Technology (IT) personnel were new to their positions and were responsible for the error. The BOM had sent the nursing employees' identification numbers and hours worked, but the IT staff failed to submit the nursing staff hours correctly, leading to the omission of RN hours in the PBJ report. The Nursing Home Administrator (NHA) confirmed the oversight and indicated that the facility became aware of the missing hours only when informed by the surveyor. Despite the error in reporting, surveyors observed sufficient staffing during their visit, and residents and their representatives did not express concerns about staffing or care provision.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility did not ensure all allegations of abuse and neglect were reported to the Nursing Home Administrator (NHA) or the State Agency (SA) for three residents. Resident 8 reported that a Certified Nursing Assistant (CNA) was short with them and denied them their face cream. This allegation was not reported to the NHA or the SA. Resident 9 reported that it took 45 minutes for a CNA to respond to their toileting request, and the CNA was rude and unwilling to assist with bathing. This allegation was also not reported to the NHA or the SA. Resident 10's daughter reported that Resident 10 was crying and stated that staff were mean and hurt them. This allegation was similarly not reported to the NHA or the SA. The facility's Abuse/Mistreatment policy contained conflicting information related to reporting allegations of abuse/mistreatment. The policy indicated that all violations and substantiated incidents should be reported to the proper state agency, registry/licensing authorities, and local law enforcement as required. However, regulatory requirements indicate that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported. The facility's Grievance policy indicated that the Grievance Official or designee should immediately report and take action pertaining to alleged violations involving neglect, abuse, mistreatment, exploitation, injuries of unknown source, and/or misappropriation of resident property. Despite these policies, the allegations involving Residents 8, 9, and 10 were not reported to the NHA or the SA, leading to a deficiency in the facility's handling of abuse and neglect reports.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility did not ensure allegations of abuse and neglect were thoroughly investigated for three residents. Resident 8 reported that a CNA was short with them and denied them their face cream. The grievance report for this incident lacked thorough investigation details, including resident interviews, witness statements, and documentation on how the resident was protected during the investigation. The grievance was ultimately deemed unsubstantiated, and staff were re-educated and disciplined for not following the care plan. Resident 9 reported that it took 45 minutes for a CNA to respond to their toileting request and that the CNA was rude and unwilling to assist with a bath. The grievance report indicated that the CNA was escorted out of the building and later terminated. However, the report did not include resident interviews, witness interviews, or written staff statements, indicating a lack of thorough investigation. Resident 10's daughter reported that the resident was crying and stated that staff were mean and hurt them. The grievance report included statements from the CNAs involved and noted that the care plan was reviewed and updated. However, it did not contain resident interviews, witness interviews, or information on how the resident's safety was ensured during the investigation. The DON believed the allegations were attention-seeking and did not investigate them as abuse or neglect. The Nursing Home Administrator was not informed of these allegations.
Failure to Provide Transfer Notice
Penalty
Summary
The facility did not ensure that a resident who was hospitalized received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. The resident was transferred to the hospital for evaluation and treatment after sustaining a skin laceration during a transfer. The medical record did not contain a transfer notice, and the Director of Nursing was unable to provide one upon request. The facility's policy requires a written notification of transfer to be provided to the resident at the time of discharge, but this was not followed in this instance. Interviews with the Social Services staff and the Director of Nursing confirmed that the facility did not provide a transfer notice other than a bed hold notice. The Director of Nursing was not aware of the need to provide a written transfer notice to residents. The deficiency was identified during a review of the resident's medical record and staff interviews, highlighting a failure to comply with the facility's own policy on resident transfers.
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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 Cedarburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedarburg Health Services | 0 mi | ★★★★★ | 0 | 0 |
| Newcastle Place | 7.9 mi | ★★★★★ | 15 | 0 |
| Complete Care At Germantown | 8 mi | ★★★★★ | 1 | 0 |
| Samaritan Nursing And Rehab | 8.1 mi | ★★★★★ | 44 | 3 |
| Cedar Lake Health And Rehab Center | 8.2 mi | ★★★★★ | 13 | 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.