Cedar Lake Health and Rehab: CNA Neglect Complaints - WI
The nursing assistant who had been caring for the resident — identified in inspection records only as CNA-E — had thrown the resident's catheter bag across the room, told the resident to get dressed, and left.
That resident, identified as R6 in federal inspection records, later told surveyors the experience made them feel helpless. R6 also said the facility already knew about the concerns before inspectors arrived.
They did know. And they had decided it wasn't neglect.
The inspection at Cedar Lake Health and Rehab Center, a nursing facility at 5595 County Road Z in West Bend, was conducted on September 29, 2025, in response to a complaint. What surveyors found was a pattern of behavior by a single nursing assistant, multiple residents who had formally complained, a corrective action plan that acknowledged the problems, and an administrator who told inspectors the facility did not believe any of it rose to the level of abuse or neglect requiring a report to the state.
The second resident affected, R8, had been admitted to the facility with myasthenia gravis, dementia, and chronic kidney disease. A cognitive assessment completed in late July 2025 placed R8's score at 12 out of 15, indicating moderately impaired cognition. R8 had an activated Power of Attorney for Healthcare for medical decisions.
In a grievance dated August 20, 2025, R8 described a consistent pattern with CNA-E: every time CNA-E provided care, CNA-E would refuse to do what R8 asked and instead tell R8 to do it themselves. R8 asked CNA-E each night to move the garbage can next to the bed. CNA-E did not move it. When R8 asked CNA-E to remove a shirt or pull a table closer, CNA-E said R8 could do it alone.
R8 told surveyors that CNA-E had a long, sad look and never smiled. When asked whether CNA-E might have been trying to encourage independence, R8 was direct: R8 didn't think so, because R8 could still do things independently, including using the bathroom at night. When R8 asked for help, R8 said, it was because R8 needed help.
The situation with R8 went beyond inconvenience. A licensed practical nurse, identified as LPN-I, documented an interview with R8 on August 26, 2025. R8 told LPN-I that CNA-E had placed R8 on the toilet and then instructed R8 to remove their own brief and put on a new one. R8 tried. While doing so, R8's ring cut into R8's leg, causing a skin tear.
In a written statement reviewed by surveyors, R8 said CNA-E's behavior made R8 feel like CNA-E didn't want to help, or didn't like helping.
The facility did put a corrective action plan in place for CNA-E. That plan acknowledged that both R6 and R8 had requested CNA-E not provide their care going forward. CNA-E was instructed not to leave residents with tasks they could not complete, to review residents' care plans before providing assistance, and not to tell residents that CNA-E was too busy to help.
The existence of that corrective action plan is significant. It means the facility had concluded, at some level, that the behavior was real enough to require a written response and formal instructions to the employee. CNA-E was told, in writing, not to abandon residents mid-task, not to claim to be too busy, not to leave people without the ability to call for help.
And yet, when a surveyor reached Nursing Home Administrator A by phone on October 15, 2025, the administrator said the facility did not believe the grievances should have been reported to the state agency as abuse or neglect. The administrator described the evidence as subjective.
The federal deficiency cited in the inspection, tagged F0609, concerns a facility's obligation to report allegations of abuse, neglect, exploitation, and injuries of unknown origin to the state agency and to the Centers for Medicare and Medicaid Services. The level of harm was cited as minimal harm or potential for actual harm.
But the description of what happened to R6 is not abstract. A catheter bag thrown across a room. A resident left on a toilet, unable to reach the call light, calling out for help for half an hour. Pants on the floor. The nursing assistant gone.
R6 told surveyors the experience left R6 feeling helpless. That word, helpless, appears in the inspection record not as a clinical assessment but as a direct quote from a person describing what it felt like to be left alone and unable to summon help.
R8 got a skin tear.
The facility's position, as stated by its administrator, is that this is subjective. The corrective action plan the facility itself wrote tells a different story — one where the behavior was documented, confirmed enough to require a formal response, and serious enough that two residents asked never to be cared for by that employee again.
Whether CNA-E remains employed at the facility is not stated in the inspection record. Whether any discipline beyond the corrective action plan was imposed is not stated. Whether R6 and R8's requests to have CNA-E removed from their care were honored going forward is not stated.
What is stated is that R8, a person with dementia and a serious neuromuscular disease, sat on a toilet and tried to change their own brief because a nursing assistant told them to, and cut themselves doing it. And that the facility looked at that, and at R6 yelling for thirty minutes from a bathroom floor with no call light, and decided the state didn't need to know.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Lake Health and Rehab Center from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
Cedar Lake Health and Rehab Center in West Bend, WI was cited for neglect violations during a health inspection on September 29, 2025.
That resident, identified as R6 in federal inspection records, later told surveyors the experience made them feel helpless.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.