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)
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
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
75
Certified beds
Average residents
56
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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.54
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.83
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.21
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.09
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.54
CMS adjusted RN staffing hours
Adjusted total hours
4.85
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
850
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0178
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.48
Baseline 21.40% · Performance 18.43% · Measure score 6.48 · Achievement 6.48 · Improvement 6.29
Healthcare-associated infections
6.19
Baseline 4.46% · Performance 5.99% · Measure score 6.19 · Achievement 6.19 · Improvement 0
Total nurse turnover
6.71
Baseline 29.11% · Performance 36.25% · Measure score 6.71 · Achievement 6.71 · Improvement 0
Adjusted total nurse staffing
5.82
Baseline 4.27 hours · Performance 4.73 hours · Measure score 5.82 · Achievement 5.82 · Improvement 2.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 283 · Observed rate 9.19% · Lower 95% interval 7.4% |
| Discharge to community | 70.13% |
50.57%
19.6 pts better
|
Better than the National Rate · Eligible stays 281 · Observed rate 67.97% · Lower 95% interval 65.46% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.21% |
95.27%
5.1 pts worse
|
Numerator 175 · Denominator 194 |
| Falls with major injury | 1.55% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 194 |
| Discharge self-care score | 59.76% |
53.69%
6.1 pts better
|
Numerator 98 · Denominator 164 |
| Discharge mobility score | 60.37% |
50.94%
9.4 pts better
|
Numerator 99 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 4.12% |
2.29%
1.8 pts worse
|
Numerator 8 · Denominator 194 · Adjusted rate 5.1% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 4.23% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 13.08% |
8.2%
4.9 pts better
|
Numerator 31 · Denominator 237 |
| Staff flu vaccination coverage | 93.77% |
42%
51.8 pts better
|
Numerator 301 · Denominator 321 |
| Discharge function score | 60.37% |
56.45%
3.9 pts better
|
Numerator 99 · Denominator 164 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 173 · Denominator 173 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.63% |
25.2%
20.4 pts better
|
Numerator 47 · Denominator 103 |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.7% · 4Q avg 99.2% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 2.9% · Q2 6.7% · Q3 3.2% · Q4 6.7% · 4Q avg 4.8% · Used in QM five-star |
| 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 · Q1 3.2% · Q2 3.4% · Q3 3.3% · Q4 0.0% · 4Q avg 2.5% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 7.1% · Q4 0.0% · 4Q avg 2.0% |
| 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 · Q1 4.0% · Q2 4.0% · Q3 10.3% · Q4 11.1% · 4Q avg 7.5% |
| 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 · Q1 4.2% · Q2 9.1% · Q3 10.7% · Q4 16.7% · 4Q avg 10.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 38.3% · Used in QM five-star |
| 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 · Q1 20.0% · Q2 20.8% · Q3 11.1% · Q4 26.9% · 4Q avg 19.6% · Used in QM five-star |
| 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 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 6.9% · Q3 0.0% · Q4 3.4% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 41.3% · Q2 45.8% · Q3 26.3% · Q4 40.2% · 4Q avg 38.1% |
| 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 · Q1 14.5% · Q2 6.6% · Q3 6.2% · Q4 7.8% · 4Q avg 8.8% · Used in QM five-star |
| 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 · Q1 91.2% · Q2 90.3% · Q3 90.0% · Q4 88.5% · 4Q avg 90.0% |
| 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 · Adjusted 13.7% · Observed 11.9% · Expected 9.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 92.8% |
| 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 · Adjusted 25.4% · Observed 19.4% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
What sits behind the stars
Ownership
Blaubach, Tracy
Operational/Managerial Control · Individual
Deruyter, Kelli
Operational/Managerial Control · Individual
Fullhart, Jennifer
Operational/Managerial Control · Individual
Goyal, Alok
Operational/Managerial Control · Individual
Karls, James
Corporate Director · Individual
Malchow, Sarah
Operational/Managerial Control · Individual
Miller, Todd
Operational/Managerial Control · Individual
Pretre, Nicole
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pavilion at Glacier Valley
Slinger, WI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Samaritan Nursing And Rehab
West Bend, WI
1-star overall rating with 1-star inspections with $75,498 in total fines with 29 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Cedarburg Health Services
Cedarburg, WI
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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