Cedar Lake Health And Rehab Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

feel good to overhear inappropriate language but did not cause Resident R6 harm. Resident R6 also indicated CNA-E threw a catheter bag across the room and left Resident R6 on the toilet with Resident R6's pants and call light on the floor. CNA-E told Resident R6 to get dressed and left the room. Resident R6 yelled for assistance for approximately 30 minutes. Resident R6 stated when Resident R6's cares were neglected and Resident R6 was left on the toilet without a call light within reach, Resident R6 felt helpless. Resident R6 indicated the facility was aware of the concerns. (See interview under example 2.)2. On 9/29/25, Surveyor reviewed Resident R8's medical record. Resident R8 was admitted to the facility on [DATE REDACTED] 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 Resident R8 had moderately impaired cognition. Resident R8 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. On 9/29/25, Surveyor reviewed

a grievance for Resident R8 that was dated 8/20/25. The grievance indicated every time CNA-E waits on Resident R8, CNA-E doesn't do what Resident R8 asks and says Resident R8 can do it by Resident R8's self. Resident R8 asks CNA-E to move the garbage can every night when Resident R8 is in bed and indicated CNA-E should know that Resident R8 wants the garbage can next to the bed at night. When Resident R8 asks CNA-E to take off Resident R8's shirt or move the table closer to the bed, CNA-E says Resident R8 can do it by Resident R8's self. Resident R8 indicated CNA-E has a long, sad look on CNA-E's face. Resident R8 asked if CNA-E ever smiles. When asked if CNA-E is trying to promote Resident R8's independence, Resident R8 didn't think so because Resident R8 can still do things independently, including go to the bathroom during the night. Resident R8 stated when Resident R8 asks staff to do something it's because Resident R8 needs help.On 9/29/25, Surveyor reviewed an interview with Licensed Practical Nurse (LPN)-I, dated 8/26/25, that indicated Resident R8 told LPN-I that CNA-E put Resident R8 on the toilet and told Resident R8 to take Resident R8's brief off and put on a new one. Resident R8 stated Resident R8 tried to remove the brief and got a skin tear when Resident R8's ring cut Resident R8's leg.On 9/29/25, Surveyor reviewed a statement by Resident R8 that indicated CNA-E's behavior made Resident R8 feel like CNA-E didn't want or like to help Resident R8.On 9/29/25, Surveyor reviewed CNA-E's corrective action plan for Resident R6 and Resident R8's concerns. The action plan indicated Resident R6 and Resident 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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Lake Health and Rehab Center

5595 Cty Rd Z West Bend, WI 53095

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

15 which indicated Resident R6 was not cognitively impaired. Resident R6 did not have an activated POAHC.On 9/29/25 at 11:48 AM, Surveyor interviewed Resident R6 who indicated Resident R6 heard staff used inappropriate language during cares, including motherfucker and that fuck, on more than one occasion. Resident R6 indicated it did not feel good to hear inappropriate language but it did not cause Resident R6 harm. Resident R6 also indicated CNA-E threw a catheter bag across the room and left Resident R6 on the toilet with Resident R6's pants and call light on the floor. CNA-E told Resident R6 to get dressed and left the room. Resident R6 yelled for assistance for approximately 30 minutes. Resident R6 indicated Resident R6 felt helpless when CNA-E neglected Resident R6's cares and left Resident R6 on the toilet without a call light within reach. Resident 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 Resident R8 and Resident 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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