West Bend, WI

Cedar Lake Health And Rehab Center

4-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

5595 Cty Rd Z, West Bend, WI

(262) 306-2100

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1990-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.54

Registered nurse staffing

LPN hours / resident day

0.35

Licensed practical nurse staffing

Aide hours / resident day

2.95

Nurse aide staffing

Weekend hours

4.21

Weekend nurse staffing

RN turnover

24%

Annual RN turnover

Total nurse turnover

37%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	95.7% 3.5 pts better	93.4% 5.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	4.8%	3.2% 1.6 pts worse	3.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	2.5%	5.0% 2.5 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	2.0%	4.9% 2.9 pts better	5.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	7.5%	16.6% 9.1 pts better	19.6% 12.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	10.2%	16.7% 6.5 pts better	16.7% 6.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	38.3%	21.1% 17.2 pts worse	16.3% 22 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	19.6%	17.3% 2.3 pts worse	14.9% 4.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	2.3% 1.2 pts better	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	2.5%	3.0% 0.5 pts better	1.7% 0.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	38.1%	25.5% 12.6 pts worse	19.8% 18.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	8.8%	5.5% 3.3 pts worse	5.1% 3.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.0%	86.8% 3.2 pts better	81.7% 8.3 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	13.7%	15.0% 1.3 pts better	12.0% 1.7 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.8%	82.2% 10.6 pts better	79.7% 13.1 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.4%	22.7% 2.7 pts worse	23.9% 1.5 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-19 · Fire 2025-02-19

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-12-06 · Fire 2023-12-06

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2022-09-22 · Fire 2022-09-22

0 health deficiencies

No concentrated health issue counts in this cycle.

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-03

F · Potential for more than minimal harm 2025-02-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-12

E · Potential for more than minimal harm 2025-02-19

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-02-19

K222 · Egress Deficiencies

Fire Safety

Add 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.

Corrected 2025-03-12

E · Potential for more than minimal harm 2025-02-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-07

E · Potential for more than minimal harm 2025-02-19

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-03-06

E · Potential for more than minimal harm 2025-02-19

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2025-03-06

E · Potential for more than minimal harm 2025-02-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-02-19

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-03-07

F · Potential for more than minimal harm 2023-12-06

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-02-02

F · Potential for more than minimal harm 2023-12-06

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-12-06

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2024-03-28

E · Potential for more than minimal harm 2023-12-06

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-12-06

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-01-16

D · Potential for more than minimal harm 2023-12-06

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-12-23

D · Potential for more than minimal harm 2023-12-06

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-12-21

D · Potential for more than minimal harm 2023-12-06

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-12-06

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-12-22

C · Minimal harm 2023-12-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-07

C · Minimal harm 2023-12-06

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-12-13

C · Minimal harm 2023-12-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-01-06

F · Potential for more than minimal harm 2022-09-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-10-15

E · Potential for more than minimal harm 2022-09-22

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2022-10-21

D · Potential for more than minimal harm 2022-09-22

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2022-09-22

D · Potential for more than minimal harm 2022-09-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-09-22

D · Potential for more than minimal harm 2022-09-22

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-22

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-10-07

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-29

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-12-17

D · Potential for more than minimal harm 2025-09-29

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-12-17

D · Potential for more than minimal harm 2025-06-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-06-30

D · Potential for more than minimal harm 2025-06-12

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-06-30

F · Potential for more than minimal harm 2025-02-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-19

D · Potential for more than minimal harm 2025-02-19

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-03-19

D · Potential for more than minimal harm 2025-02-19

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-03-19

D · Potential for more than minimal harm 2025-02-19

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-03-19

D · Potential for more than minimal harm 2025-02-19

F887 · Infection Control Deficiencies

Health

Educate 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.

Corrected 2025-03-19

F · Potential for more than minimal harm 2023-12-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-12-06

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-03

Penalties and ownership