Cedar Lake Health and Rehab: Neglect Violations - WI
That is what federal inspectors documented at Cedar Lake Health and Rehab Center following a complaint inspection conducted September 29, 2025.
The resident, identified in inspection records as R6, told the surveyor what it felt like to sit there, unable to get up, unable to summon help, waiting. R6 used one word: helpless.
The aide, identified as CNA-E, did not return.
What happened next inside Cedar Lake's management may matter as much as what CNA-E did. When inspectors pressed the facility's Director of Nursing, identified as DON-B, on whether the incident had triggered any mandatory all-staff education on abuse and neglect, DON-B's answer was direct: no. DON-B called the CNA-E incident isolated. All-staff retraining, DON-B said, was not required.
The Nursing Home Administrator, identified as NHA-A, told inspectors something different. NHA-A said all-staff education should be completed any time a verified form of abuse or neglect occurs.
The two people responsible for running the facility gave inspectors two different answers about what their own facility's response to verified neglect was supposed to look like.
The inspection covered at least two residents, R6 and another identified as R8, both of whom had filed grievances. According to inspection records, the facility did provide some all-staff CNA education as part of resolving those grievances. DON-B confirmed the date that training was initiated: July 21, 2025. The grievances it was meant to address came in a month later.
The training preceded the complaints it was supposed to fix.
Three nursing aides, identified as CNA-F, CNA-G, and CNA-H, told inspectors on the afternoon of September 29 that the last time they received any abuse and neglect education was June 2025. That was three months before inspectors showed up, and it predated both grievances.
The inspection report does not describe what happened to R8 in the same level of detail it describes what happened to R6. What it does establish is that R8 also filed a grievance, that the facility treated both situations as part of the same resolution process, and that the resolution process involved training that had already happened before either resident complained.
R6's account, as recorded by the surveyor, is the clearest window into what the neglect looked like on the ground. CNA-E entered the room. At some point during the interaction, the catheter bag was thrown. R6 was left sitting on the toilet. The call light, the one tool a resident has to summon help when staff have left the room, was on the floor. R6's pants were also on the floor. CNA-E told R6 to get dressed and left.
A resident sitting on a toilet cannot easily retrieve a call light from the floor. That is not a hypothetical. R6 sat there and yelled. For approximately 30 minutes, nobody came.
R6 told the surveyor the facility was aware of the concerns. That phrase, "the facility was aware," sits in the inspection record without elaboration. The report does not say when the facility became aware, who was told, or what, if anything, was done before inspectors arrived.
What inspectors found when they arrived was a Director of Nursing who believed the incident was isolated and that no broader staff education was warranted, and a Nursing Home Administrator who believed the opposite. The inspection record does not indicate whether those two individuals had ever compared their positions before September 29.
The CMS inspection form categorizes the harm level for this violation as "minimal harm or potential for actual harm" and notes that some residents were affected. That classification reflects the regulatory framework inspectors use. It does not mean R6 experienced the situation as minor. R6 described feeling helpless. R6 yelled for thirty minutes. The distinction between what the form says and what R6 said matters.
Nursing aides in Wisconsin long-term care facilities are required to complete training on abuse and neglect prevention as a condition of their certification. When a facility substantiates a neglect incident, the expectation, as NHA-A acknowledged to inspectors, is that all-staff education follows. DON-B's position that CNA-E's conduct was isolated and required no such response reflects a judgment call. It is a judgment call the Nursing Home Administrator directly contradicted.
The three aides who spoke to inspectors that afternoon, CNA-F, CNA-G, and CNA-H, had not received any abuse or neglect education since June. They were not the aide who left R6 on the toilet. They were the staff working the halls of Cedar Lake while the facility's two top administrators held opposing views about what the facility's own obligations were.
None of that is unusual in isolation. Staff rosters turn over. Training calendars slip. Administrators sometimes have different readings of policy. What makes Cedar Lake's situation notable is the specific sequence: a resident left without a call light on a toilet for thirty minutes, a grievance filed, a Director of Nursing who decided no broader action was needed, an administrator who said the opposite, and a training record that showed the most recent education happened before either complaint existed.
R6 told inspectors the facility was aware. The record suggests the facility was aware and reached different conclusions about what awareness required of them.
The inspection was a complaint survey, meaning it was triggered by a specific allegation rather than a routine annual review. The report does not identify who filed the complaint. It identifies what inspectors found when they looked.
What they found was a resident who had been left, a call light on the floor, a catheter bag thrown, and thirty minutes of yelling into an empty hallway. They found a nursing staff whose most recent neglect training was a quarter-year old. They found a Director of Nursing and a Nursing Home Administrator who, when asked the same question about the same incident, gave answers that could not both be right.
R6 said the facility was aware of the concerns. R6 also said R6 felt helpless.
Both of those things appear to be true.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 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 is what federal inspectors documented at Cedar Lake Health and Rehab Center following a complaint inspection conducted September 29, 2025.
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.