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CEDAR LAKE HEALTH AND REHAB CENTER

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CEDAR LAKE HEALTH AND REHAB CENTER is a non profit - church related facility in WEST BEND, WI with 75 certified beds and a 4-star overall CMS rating. The facility has 11 deficiency records on file.

5595 CTY RD Z, WEST BEND, WI 53095

Phone: 2623062100

Overall Rating

4/5

Health Inspection

3/5

Staffing

5/5

Quality Measures

3/5

Long-Stay Quality

1/5

Facility Information

Provider Number
525465
Ownership
Non profit - Church related
Provider Type
Medicare and Medicaid
Beds
75
Residents
56
In Hospital
No
County
Washington
Last Inspection
Feb 19, 2025

Staffing Data

RN Hours
1.54 (nat'l avg: 0.68)
LPN Hours
0.35
CNA Hours
2.95
Total Nursing Hours
4.83 (nat'l avg: 3.89)
PT Hours
0.13
Nursing Turnover
36.5%
RN Turnover
23.8%

What the CMS Record Reveals About CEDAR LAKE HEALTH AND REHAB CENTER

CEDAR LAKE HEALTH AND REHAB CENTER operates 75 certified beds in WEST BEND, WI with approximately 56 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (5★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 11 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.83 total nursing hours per resident day (national average 3.89), with RN coverage at 1.54 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, CEDAR LAKE HEALTH AND REHAB CENTER falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 36.5%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (11 most recent)

E — Pattern - Minimal harm Sep 29, 2025 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Dec 17, 2025

D — Isolated - Minimal harm Sep 29, 2025 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Dec 17, 2025

D — Isolated - Minimal harm Jun 12, 2025 Tag: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jun 30, 2025

D — Isolated - Minimal harm Jun 12, 2025 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 30, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0887

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Category: Infection Control Deficiencies

Corrected: Mar 19, 2025

F — Widespread - Minimal harm Feb 19, 2025 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Mar 19, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Category: Pharmacy Service Deficiencies

Corrected: Mar 19, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 19, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0623

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Category: Resident Rights Deficiencies

Corrected: Mar 19, 2025

F — Widespread - Minimal harm Dec 6, 2023 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Dec 22, 2023

D — Isolated - Minimal harm Dec 6, 2023 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 3, 2024

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 19.6% Yes
Percentage of long-stay residents who lose too much weight Long Stay 2.0% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 1.1% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 2.5% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 2.5% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 4.8% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 99.2% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 90.0% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 0.0% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 38.3% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 7.5% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 92.8% No
Percentage of long-stay residents with pressure ulcers Long Stay 8.8% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 38.1% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 10.2% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for CEDAR LAKE HEALTH AND REHAB CENTER?
CEDAR LAKE HEALTH AND REHAB CENTER has an overall CMS rating of 4 out of 5 stars. This rating combines health inspection results (3★), staffing levels (5★), and quality measures (3★).
What are the staffing levels at CEDAR LAKE HEALTH AND REHAB CENTER?
CEDAR LAKE HEALTH AND REHAB CENTER reports 4.83 total nursing hours per resident day (national average: 3.89). RN hours are 1.54 per resident day (national average: 0.68). Nursing staff turnover is 36.5%.
How many beds does CEDAR LAKE HEALTH AND REHAB CENTER have?
CEDAR LAKE HEALTH AND REHAB CENTER has 75 certified beds with approximately 56 residents. The facility is located at 5595 CTY RD Z, WEST BEND, WI 53095.
Does CEDAR LAKE HEALTH AND REHAB CENTER have any deficiencies on record?
Yes, CEDAR LAKE HEALTH AND REHAB CENTER has 11 deficiencies on record from recent inspections. Most deficiencies are classified as no harm or minimal harm.
Has CEDAR LAKE HEALTH AND REHAB CENTER received any fines or penalties?
No, CEDAR LAKE HEALTH AND REHAB CENTER has no fines or penalties on record.
Who owns CEDAR LAKE HEALTH AND REHAB CENTER?
CEDAR LAKE HEALTH AND REHAB CENTER is classified as "Non profit - Church related" ownership. The facility type is "Medicare and Medicaid".
When was CEDAR LAKE HEALTH AND REHAB CENTER last inspected?
The most recent health inspection for CEDAR LAKE HEALTH AND REHAB CENTER was on Feb 19, 2025. The facility received a health inspection rating of 3 out of 5 stars.
What quality measures are tracked for CEDAR LAKE HEALTH AND REHAB CENTER?
CEDAR LAKE HEALTH AND REHAB CENTER is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial