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Cedar Lake Health and Rehab Center Inspection Report, Violations & Safety Grade (West Bend, Wisconsin)

5595 CTY RD Z, West Bend, Wisconsin 53095

Phone: 2623062100

CMS Overall:5/5

Overview & Bed Count

Certified Beds
75
Avg Residents/Day
55.1
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Washington
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health4/5
Staffing5/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityWisconsin AvgDifference
RN Hours per Resident per Day1.530.98+0.55
Total Nurse Hours per Resident per Day5.224.25+0.97
CMS Staffing Rating5/53.7/5-
Nursing Staff Turnover39.8%46.7%-

Health Citation History

14 health citations on record

DateCategoryDescriptionSeverity
2026-06-24Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2026-06-24Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2026-04-21Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.E – Moderate Harm Potential
2025-09-29Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.E – Moderate Harm Potential
2025-09-29Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2025-06-12Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2025-06-12Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2025-02-19Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-02-19Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.D – Moderate Harm Potential
2025-02-19Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2025-02-19Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2025-02-19Infection Control DeficienciesEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.D – Moderate Harm Potential
2023-12-06Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-12-06Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential

Fire Safety Citation History

29 fire safety citations on record

DateCategoryDescriptionSeverity
2026-04-21Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2026-04-21Construction DeficienciesMeet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.E – Moderate Harm Potential
2026-04-21Gas, Vacuum, and Electrical Systems DeficienciesHave power receptacles that are properly grounded.E – Moderate Harm Potential
2026-04-21Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.E – Moderate Harm Potential
2026-04-21Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.D – Moderate Harm Potential
2026-04-21Smoke DeficienciesInstall an approved automatic sprinkler system.D – Moderate Harm Potential
2026-04-21Smoke DeficienciesEnsure that corridors are separated from use areas by walls constructed to limit the passage of smoke.D – Moderate Harm Potential
2026-04-21Gas, Vacuum, and Electrical Systems DeficienciesHave proper fire barriers, ventilation and signs for the transfilling of oxygen.D – Moderate Harm Potential
2025-02-19Smoke DeficienciesProvide properly protected cooking facilities.F – Moderate Harm Potential
2025-02-19Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2025-02-19Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.E – Moderate Harm Potential
2025-02-19Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.E – Moderate Harm Potential
2025-02-19Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2025-02-19Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.E – Moderate Harm Potential
2025-02-19Miscellaneous DeficienciesHave restrictions on the use of highly flammable decorations.E – Moderate Harm Potential
2025-02-19Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.E – Moderate Harm Potential
2025-02-19Construction DeficienciesUse approved construction type or materials.D – Moderate Harm Potential
2023-12-06Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2023-12-06Miscellaneous DeficienciesProvide a written emergency evacuation plan.F – Moderate Harm Potential
2023-12-06Construction DeficienciesMeet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.E – Moderate Harm Potential
2023-12-06Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2023-12-06Smoke DeficienciesProvide properly protected cooking facilities.D – Moderate Harm Potential
2023-12-06Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.D – Moderate Harm Potential
2023-12-06Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2023-12-06Miscellaneous DeficienciesHave restrictions on the use of portable space heaters.D – Moderate Harm Potential
2023-12-06Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.D – Moderate Harm Potential
2023-12-06Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.C – Minimal Harm Potential
2023-12-06Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.C – Minimal Harm Potential
2023-12-06Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.C – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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