Cedar Lake Health and Rehab: Dignity Violations Found - WI
That finding was one of two complaints federal inspectors examined during a September 29, 2025 survey of the facility at 5595 County Road Z. What they found was a pattern: one nursing aide, identified in the inspection report as CNA-E, repeatedly refused to assist two residents with tasks those residents said they could not complete on their own. The facility's response was to call the complaints subjective and decide the situation didn't need to be reported as potential neglect.
The first resident, identified as R6, was left on the toilet without a call light within reach. The inspection report states R6 felt helpless. R6 told inspectors the facility was already aware of the concerns.
The second resident, R8, had been admitted to the facility and carried diagnoses of myasthenia gravis, dementia, and chronic kidney disease. Myasthenia gravis is a neuromuscular disease that causes muscle weakness, including in the limbs and hands. An assessment completed in July 2025 gave R8 a cognitive score of 12 out of 15, indicating moderately impaired cognition. R8 had a Power of Attorney for Healthcare in place for medical decisions.
On August 20, 2025, R8 filed a grievance. It described a consistent pattern with CNA-E: every time CNA-E provided care, CNA-E refused to do what R8 asked and told R8 to do it independently. R8 asked CNA-E each night to move the garbage can next to the bed. CNA-E didn't do it. When R8 asked CNA-E to take off R8's shirt, or to move the table closer to the bed, CNA-E said R8 could do it alone.
R8 noticed something else. CNA-E had, as R8 described it, a long, sad look on CNA-E's face. R8 asked CNA-E directly whether CNA-E ever smiles.
When investigators asked R8 whether CNA-E might have been trying to encourage independence, R8 pushed back. R8 said there was no reason to think so, because R8 was still capable of doing things independently, including getting up to use the bathroom during the night without help. R8 was clear about the distinction: when R8 asked for help, it was because R8 needed it.
Then came the skin tear.
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 R8's own brief and put on a new one. R8 tried. In the process, R8's ring cut R8's leg, causing a skin tear.
R8's own written statement described the effect of CNA-E's behavior plainly: it made R8 feel like CNA-E didn't want or like to help R8.
The facility did produce a corrective action plan for CNA-E following the grievances from both R6 and R8. The plan noted that both residents had asked that CNA-E not provide care for them. CNA-E was directed not to leave residents with tasks they could not complete, to review residents' care plans, and not to tell residents that CNA-E was too busy to help.
That document acknowledged the problem. What the facility did next is where the inspection report focuses its sharpest finding.
On October 15, 2025, the nursing home administrator, identified as NHA-A, spoke with the surveyor by phone. NHA-A said the facility did not believe the grievances needed to be reported to the state agency as potential abuse or neglect. NHA-A said the evidence was subjective.
The administrator's position was that what two residents separately reported, what a nurse documented, what a corrective action plan confirmed, and what resulted in a physical injury to one resident did not clear the bar for a neglect report.
R8 had myasthenia gravis and dementia. R8 was placed on a toilet and told to change R8's own brief. R8 cut R8's leg doing it. The facility reviewed all of this and concluded the evidence was too subjective to report.
R6 was left on a toilet without a call light. R6 felt helpless. The facility knew.
What the inspection report captures, across both cases, is not a single lapse or a misread situation. CNA-E's behavior toward R8 was documented as recurring, consistent enough that R8 noticed CNA-E's facial expression and thought to ask whether CNA-E ever smiles. The grievance R8 filed described not one incident but a pattern: every time. The corrective action plan's instruction that CNA-E should not tell residents CNA-E is too busy suggests that phrase had been used, more than once, to residents who had come to this facility because they needed help.
Cedar Lake Health and Rehab is a licensed nursing facility. The residents it serves are there because they cannot manage their care alone. R8, with a neuromuscular disease that weakens muscles and moderately impaired cognition, asked a nursing aide to move a garbage can to the bedside each night. That request was refused, repeatedly, by someone whose job is to provide exactly that kind of assistance.
The inspection was classified as a complaint survey. The level of harm was listed as minimal harm or potential for actual harm, affecting few residents. That classification exists on a spectrum that goes much higher. But the skin tear on R8's leg was real. The helplessness R6 felt on the toilet was real. The feeling R8 described, that CNA-E didn't want or like to help, was real enough that R8 put it in writing.
The facility's corrective action plan told CNA-E to review the care plans and stop leaving residents with tasks they cannot complete. It did not say those tasks were unreasonable to begin with. Moving a garbage can. Moving a table closer to the bed. Removing a shirt. These are not complex clinical interventions. They are the basic accommodations that make a nursing home room livable for someone who cannot always do those things alone.
R8 asked CNA-E if CNA-E ever smiles. The inspection report does not record an answer.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
Cedar Lake Health and Rehab Center in West Bend, WI was cited for violations during a health inspection on September 29, 2025.
That finding was one of two complaints federal inspectors examined during a September 29, 2025 survey of the facility at 5595 County Road Z.
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.