Cedar Lake Health And Rehab Center
Cedar Lake Health and Rehab Center in West Bend, WI — inspection on September 29, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
feel good to overhear inappropriate language but did not cause R6 harm. R6 also indicated CNA-E threw a catheter bag across the room and left R6 on the toilet with R6's pants and call light on the floor. CNA-E told R6 to get dressed and left the room. R6 yelled for assistance for approximately 30 minutes. R6 stated when R6's cares were neglected and R6 was left on the toilet without a call light within reach, R6 felt helpless. R6 indicated the facility was aware of the concerns. (See interview under example 2.)2. On 9/29/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including myasthenia gravis, dementia, and chronic kidney disease. An MDS assessment completed on 7/30/25 included a BIMS score of 12 out of 15 which indicated R8 had moderately impaired cognition. R8 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. On 9/29/25, Surveyor reviewed a grievance for R8 that was dated 8/20/25.
The grievance indicated every time CNA-E waits on R8, CNA-E doesn't do what R8 asks and says R8 can do it by R8's self. R8 asks CNA-E to move the garbage can every night when R8 is in bed and indicated CNA-E should know that R8 wants the garbage can next to the bed at night.
When R8 asks CNA-E to take off R8's shirt or move the table closer to the bed, CNA-E says R8 can do it by R8's self. R8 indicated CNA-E has a long, sad look on CNA-E's face. R8 asked if CNA-E ever smiles.
When asked if CNA-E is trying to promote R8's independence, R8 didn't think so because R8 can still do things independently, including go to the bathroom during the night. R8 stated when R8 asks staff to do something it's because R8 needs help.On 9/29/25, Surveyor reviewed an interview with Licensed Practical Nurse (LPN)-I, dated 8/26/25, that indicated R8 told LPN-I that CNA-E put R8 on the toilet and told R8 to take R8's brief off and put on a new one. R8 stated R8 tried to remove the brief and got a skin tear when R8's ring cut R8's leg.On 9/29/25, Surveyor reviewed a statement by R8 that indicated CNA-E's behavior made R8 feel like CNA-E didn't want or like to help R8.On 9/29/25, Surveyor reviewed CNA-E's corrective action plan for R6 and R8's concerns.
The action plan indicated R6 and R8 asked that CNA-E not provide care for them. CNA-E was asked not to leave residents with tasks they cannot complete, to review residents' Kardexes (abbreviated care plans used by nursing staff) and plans of care, and not to tell residents that CNA-E is too busy to provide assistance.On 10/15/25 at 2:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A via phone who indicated the facility did not feel the grievances should be reported to the SA for abuse/neglect and found the evidence to be subjective.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Lake Health and Rehab Center
5595 Cty Rd Z West Bend, WI 53095
SUMMARY STATEMENT OF DEFICIENCIES
15 which indicated R6 was not cognitively impaired. R6 did not have an activated POAHC.On 9/29/25 at 11:48 AM, Surveyor interviewed R6 who indicated R6 heard staff used inappropriate language during cares, including motherfucker and that fuck, on more than one occasion. R6 indicated it did not feel good to hear inappropriate language but it did not cause R6 harm. R6 also indicated CNA-E threw a catheter bag across the room and left R6 on the toilet with R6's pants and call light on the floor. CNA-E told R6 to get dressed and left the room. R6 yelled for assistance for approximately 30 minutes. R6 indicated R6 felt helpless when CNA-E neglected R6's cares and left R6 on the toilet without a call light within reach. R6 indicated the facility was aware of the concerns.On 9/29/25 from 1:25 PM to 1:40 PM, Surveyor interviewed CNA-F, CNA-G, and CNA-H who verified they last received abuse/neglect education in June of 2025.On 9/29/25 at 2:12 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the incident with CNA-C was isolated and all staff education was not required. DON-B verified the all staff CNA education provided as a resolution for R8 and R6's grievances was initiated on 7/21/25 which was a month prior to the grievances. On 9/29/25 at 2:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated all staff education should be completed for any verified form of abuse/neglect.
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