CEDAR LAKE HEALTH AND REHAB CENTER

WEST BEND, WI · 75 beds · Non profit - Church related

86 Trust Score
Grade: A LOW Risk → Stable

Red Flags

No red flags identified.

Green Flags

  • 5-star staffing rating
  • No fines or penalties on record
  • Above-average RN staffing (1.54 hrs vs 1.00 state avg)

Quick Facts

★★★★☆
CMS Overall
★★★☆☆
Health Inspection
9
0.9x state avg
Deficiencies
$0
Fines (3-yr)
★★★★★
Staffing

Violation Timeline

September 28, 2025

2 deficiencyies
F0609 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

F0610 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Respond appropriately to all alleged violations.

June 11, 2025

2 deficiencyies
F0610 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Respond appropriately to all alleged violations.

F0842 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

February 18, 2025

5 deficiencyies
F0623 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0757 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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

F0887 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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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.

December 5, 2023

2 deficiencyies
F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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

See full violation history →

Staffing

1.54
RN hrs/res/day
0.35
LPN hrs/res/day
2.96
CNA hrs/res/day
4.23
Weekend hrs/res/day
37%
Total nurse turnover
24%
RN turnover

A nurse checks on each resident roughly every 4.9 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

Non profit - Church related Independent (not part of a chain)
  • BLAUBACH, TRACY

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 03/27/2018

    Individual
  • DERUYTER, KELLI

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 02/01/2024

    Individual
  • FULLHART, JENNIFER

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 10/03/2022

    Individual
  • GOYAL, ALOK

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    Individual
  • MALCHOW, SARAH

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 05/13/2019

    Individual
  • MILLER, TODD

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 11/04/2019

    Individual
  • KARLS, JAMES

    CORPORATE DIRECTOR

    Since since 11/11/2024

    Individual
  • PRETRE, NICOLE

    CORPORATE OFFICER

    Since since 05/15/2021

    Individual

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