Cedar Lake Health and Rehab Center
5595 Cty Rd Z, West Bend, WI 53095
Cedar Lake Health and Rehab Center, a 75-bed non profit - church related nursing facility in West Bend, WI, holds a 4-star CMS overall rating - well above the 3.0-star national average, with nurse staffing above the national norm. No recent finding reached the actual-harm level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 2623062100
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- 4 / 5
- Above average · CMS overall · nat'l 3.0
- 4.83
- Well above average · nurse hrs/day · nat'l 3.89
- 11
- Inspection findings
- $0
- Federal penalties (0)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
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
How the 4.83 total nursing hours per resident-day are staffed:
- 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 (health inspection 3★ · staffing 5★ · quality 3★).
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. 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.
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. Reported nursing turnover at this facility is 36.5%, within a range generally associated with stable care teams.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. 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.
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. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
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)
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 17, 2025
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
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
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 30, 2025
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
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
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Mar 19, 2025
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
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
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
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 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 experiencing one or more falls with major injury | Long Stay | 4.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 38.3% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 8.8% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.2% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.0% | No |
| 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 assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.2% | No |
| 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 long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 38.1% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 90.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 92.8% | No |
Penalty History
No penalties on record.
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Understanding Nursing Home Data
Frequently Asked Questions
What is the overall CMS rating for Cedar Lake Health and Rehab Center?
What are the staffing levels at Cedar Lake Health and Rehab Center?
How many beds does Cedar Lake Health and Rehab Center have?
Does Cedar Lake Health and Rehab Center have any deficiencies on record?
Has Cedar Lake Health and Rehab Center received any fines or penalties?
Who owns Cedar Lake Health and Rehab Center?
When was Cedar Lake Health and Rehab Center last inspected?
What quality measures are tracked for Cedar Lake Health and Rehab Center?
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.
Read our methodology - how this data is sourced, computed, and verified.
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