Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedarburg Health Services during CMS and state inspections, most recent first.
A resident with diabetes had blood sugar levels exceeding 400 mg/dL on three occasions, but the facility failed to notify the physician as required by the resident's care plan. Despite the facility's policy on notifying physicians of changes in condition, there was no documentation of such notifications, as confirmed by the Vice President of Success.
Two residents with swallowing difficulties were observed eating without staff assistance, despite care plans indicating the need for supervision. One resident showed signs of distress, yet the LPN present did not provide assistance. The facility lacked a dining assistance policy, and staff interviews revealed inconsistencies in supervision practices.
A LTC facility failed to ensure accurate medication administration for three residents. A resident with allergic rhinitis had fluticasone nasal spray at their bedside against orders. Another resident's MAR inaccurately reflected the administration time of polyethylene glycol, and a third resident was given hydralazine without a required blood pressure check, with discrepancies in their MAR as well.
A facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during observations. A resident with a history of stroke, hypertension, and seizure disorder was not administered medications as ordered. RN-D applied the wrong topical cream and failed to administer cholecalciferol and levetiracetam, despite documenting otherwise. The NHA indicated that staff should document medications as administered only when given.
Expired medications were found in a medication room, including diphenhydramine, loratadine, acetaminophen suppositories, and a COVID-19 vaccine. The DON confirmed these should have been discarded, indicating non-compliance with the facility's disposal policy.
Two residents with symptoms of upper respiratory infections were not placed on transmission-based precautions in a timely manner. One resident, with multiple sclerosis, showed symptoms on January 19 but was not isolated until January 21 after an influenza A diagnosis. Another resident, receiving hospice care, reported symptoms but was not isolated. The facility failed to adhere to infection control policies, increasing the risk of disease transmission.
Two residents in the facility did not have hot water in their bathroom sinks due to unresolved plumbing issues. One resident, with intact cognition, reported the absence of hot water since June, causing frustration and inconvenience. Another resident, with moderate cognitive impairment, also expressed dissatisfaction as it delayed their daily activities. The Maintenance Manager confirmed ongoing plumbing issues since February, and the Nursing Home Administrator acknowledged the problem, indicating efforts to address it.
A resident experienced delayed call light responses and inadequate assistance with toileting, leading to unresolved grievances. Despite the facility's policy requiring timely resolution, staff inconsistently responded to call lights, and not all were trained on the response policy. This resulted in the resident being left in discomfort and with skin issues due to prolonged exposure to urine and stool.
The facility failed to provide fluids consistently to four residents as per their nutritional assessments. Observations and interviews revealed that residents did not receive fresh drinking water regularly, and medical records showed incomplete documentation and insufficient fluid intake. Staff interviews indicated that water should be passed every few hours, but this was not always done.
The facility failed to complete timely background checks for two CNAs, violating its Abuse, Neglect, and Exploitation policy. Background checks for CNA-C and CNA-E were not obtained until well after their hire dates, as confirmed by staff interviews and record reviews.
A resident reported rough treatment by a CNA, causing pain and discomfort. The facility's investigation was incomplete, lacking a 5-day report to the State Agency, necessary interviews, and documentation. Additionally, the resident's care plans were not updated following the incident.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify a physician of blood sugar levels that exceeded the ordered parameters for a resident diagnosed with diabetes. The resident, who had intact cognition as indicated by a BIMS score of 15 out of 15, had a physician's order requiring staff to notify the physician if blood glucose levels were less than 60 or greater than 400 mg/dL. On three separate occasions, the resident's blood sugar levels were recorded as 410, 422, and 421 mg/dL, yet there was no documentation indicating that the physician was notified as required by the order. The facility's policy on Change in Condition of the Resident, dated 9/20/22, states that notifications not requiring immediate consultation with a physician may be made via phone, fax, or the physician's preferred method, and that a method to track faxes should be developed to ensure timely response. However, during an interview, the Vice President of Success confirmed that the facility could not locate any notifications to the physician regarding the resident's elevated blood sugar levels, acknowledging that staff should have notified the physician and documented the notification.
Inadequate Supervision During Meals for Residents with Swallowing Difficulties
Penalty
Summary
The facility failed to ensure adequate supervision during meals for two residents, R24 and R10, who were observed eating without staff assistance despite their care plans indicating the need for supervision due to difficulty swallowing. R24, diagnosed with dysphagia, Parkinson's disease, dementia, and other conditions, was observed eating lunch without staff assistance, coughing, drooling, and appearing in distress. Despite these signs, the LPN present continued to work on a laptop and did not provide the necessary assistance, leading to the Nursing Home Administrator eventually removing R24 from the dining room. R10, who also had difficulty swallowing and required reminders to swallow and drink at specific intervals, was similarly observed eating without staff assistance. The Director of Nursing and a CNA confirmed that staff were expected to circulate in the dining room rather than sit with residents needing assistance, contrary to the expectations of the Nursing Home Administrator and the recommendations of the Speech Therapist. The facility lacked a policy related to dining assistance, contributing to the inadequate supervision observed. Interviews with staff revealed inconsistencies in the understanding and implementation of supervision requirements during meals, which led to the deficiency in providing adequate care for residents with swallowing difficulties.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the accurate administration of medication for three residents, leading to deficiencies in pharmaceutical services. Resident 13, who had a diagnosis of allergic rhinitis and intact cognition, was observed with fluticasone nasal spray at their bedside, contrary to the physician's order and the facility's policy. The order specified that fluticasone should not be kept at the bedside due to the resident's history of overuse, yet it was found there during a surveyor's visit. The registered nurse confirmed the oversight and acknowledged the error upon review of the order. Resident 18, who had moderate cognitive impairment and multiple diagnoses including dementia and diabetes, had discrepancies in their medication administration record (MAR). The MAR inaccurately reflected the time polyethylene glycol was administered, as the nurse documented the administration at a time different from when it was actually given. The nurse admitted to administering the medication earlier than recorded, which was not in line with the facility's policy of documenting medication administration at the time it occurs. Resident 19, with moderate cognitive impairment and a history of stroke and seizure disorder, was administered hydralazine without the required blood pressure check as per the physician's order. The order specified holding the medication if the systolic blood pressure was below a certain threshold, but the nurse failed to obtain the blood pressure before administration. Additionally, the MAR inaccurately recorded the administration time of polyethylene glycol, which was documented before it was actually given. The nurse later confirmed the discrepancies in the MAR and acknowledged the errors in documentation and procedure.
Medication Administration Errors Result in 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during medication administration observations. Specifically, three errors occurred out of 30 opportunities, affecting one resident, R19, who was observed during the medication administration process. R19, who has a medical history including stroke with hemiplegia, hypertension, and seizure disorder, was not administered medications as ordered. During the observation, RN-D incorrectly applied Diclofenac 1% topical cream instead of the prescribed Biofreeze 4% menthol gel, and failed to administer cholecalciferol and levetiracetam as ordered. The surveyor's review of R19's medical records and interviews with RN-D revealed discrepancies in medication administration documentation. RN-D documented that Biofreeze and cholecalciferol were administered, although the surveyor did not observe these actions. Additionally, RN-D confirmed that levetiracetam was not administered at the scheduled time due to unavailability. The Nursing Home Administrator indicated that staff should only document medications as administered when they have been given, highlighting a failure in adherence to proper medication administration protocols.
Expired Medications Not Discarded
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were discarded when expired in one of the two medication rooms. During an observation on January 21, 2025, the surveyor and the Director of Nursing (DON) identified expired medications in the 400 unit medication room. Specifically, they found an unopened bottle of diphenhydramine HCL 25 mg tablets with an expiration date of October 2024, an open bottle of diphenhydramine HCL 25 mg tablets with an expiration date of June 2024, and an unopened bottle of loratadine 10 mg tablets with an expiration date of October 2024 in the floor stock medication cabinet. Additionally, in the medication refrigerator, they found an open box of acetaminophen 650 mg suppositories with an expiration date of December 2024 and a COVID-19 vaccine with an expiration date of May 4, 2024. The DON confirmed that these medications were expired and should have been discarded, indicating a failure to adhere to the facility's policy on the disposal of outdated medications.
Delayed Precautions for Residents with Respiratory Symptoms
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the delayed implementation of transmission-based precautions for two residents, R9 and R15, who exhibited symptoms of an upper respiratory infection. R9, who had multiple sclerosis and depression, began showing symptoms such as headache, nasal congestion, and sore throat on January 19, 2025. Despite these symptoms and a subsequent fever, R9 was not placed on droplet precautions until January 21, 2025, after being diagnosed with influenza A in the emergency room. The infection preventionist confirmed that R9 was symptomatic from January 19, 2025, but was not put on precautions until two days later. Similarly, R15, who was receiving hospice services for malignant neoplasm of the endometrium, reported feeling unwell with a sore throat, cough, and congestion starting a couple of days before January 21, 2025. Despite these symptoms and the administration of medication for cough and congestion, R15 was not placed on precautions. The infection preventionist was unaware of R15's symptoms, and the director of nursing confirmed that precautions should have been implemented at the onset of symptoms, regardless of hospice care directives. The failure to promptly implement transmission-based precautions for both residents highlights a lapse in the facility's infection control practices. The staff did not adhere to the facility's policy or CDC guidelines, which require immediate precautions for residents with symptoms of communicable diseases. This oversight potentially increased the risk of transmission of infectious agents within the facility.
Deficiency in Providing Hot Water to Residents
Penalty
Summary
The facility failed to ensure that two residents, R13 and R9, had access to hot water in their bathroom sinks, which is a deficiency in accommodating the needs and preferences of residents. On 10/4/24, observations revealed that the bathroom sinks of R13 and R9 did not have hot water. R13, who has intact cognition and requires assistance for personal care, reported not having hot water since June and expressed frustration over the inconvenience. R9, who has moderate cognitive impairment and is dependent on staff for personal care, also expressed dissatisfaction with the lack of hot water, which delayed their daily activities. The Maintenance Manager confirmed that the facility had an underground leak in February, leading to multiple excavations and a whole building water shutdown in August. Temporary water lines were installed, but three rooms, including those of R13 and R9, still lacked hot water. The Nursing Home Administrator acknowledged the issue and mentioned efforts to transition residents out of the affected rooms while working on fixing the water pipes.
Delayed Call Light Response and Unresolved Grievance
Penalty
Summary
The facility failed to resolve a grievance regarding delayed call light response times for a resident, R3, in a timely manner. The grievance was filed by R3's representative, RR-H, on behalf of R3, who experienced delays in receiving assistance for toileting needs. The facility's grievance policy required resolution within 72 hours, but the issue persisted beyond this timeframe. R3's care plan required assistance with toileting and transfers, yet staff did not consistently respond to call lights or provide timely assistance, as reported by both RR-H and R3's Power of Attorney for Healthcare (POAHC-I). Interviews and record reviews revealed that on multiple occasions, staff turned off R3's call light without providing the necessary assistance, leaving R3 in discomfort and with skin issues due to prolonged exposure to urine and stool. Staff were observed to prioritize meal tray delivery over responding to call lights, and there was inconsistency in the number of staff assisting R3 with the sit-to-stand lift. Additionally, not all staff assigned to R3's wing had received education on the facility's call light response policy, contributing to the ongoing issue. The surveyor noted that despite previous grievances and education efforts, the facility did not ensure all staff were adequately trained or that the grievance was resolved effectively. The lack of timely response to call lights and inadequate staff training led to repeated instances where R3's needs were not met, highlighting a deficiency in the facility's grievance resolution and call light response processes.
Inconsistent Provision of Fluids to Residents
Penalty
Summary
The facility did not ensure that fluids were provided consistently to four residents (R3, R4, R5, and R6) as per their nutritional assessments. Observations, staff and resident interviews, and record reviews revealed that these residents did not receive fresh drinking water regularly. R3 reported that staff were often too busy to refill the water cup, and the surveyor observed that R3's water cup contained room temperature water. R4 stated that water and ice were rarely available at night, and the surveyor noted an empty water cup on R4's bedside table. R5 mentioned that staff did not always have time to pass water, and there were evenings when R5 felt extremely thirsty. R6 indicated that the availability of water depended on how busy the staff were, and the surveyor observed an almost empty water cup from the previous evening. Medical records for these residents showed incomplete documentation and insufficient fluid intake compared to their recommended daily fluid intake. The facility's Hydration policy, reviewed on 7/26/22, mandates that each resident should be offered sufficient fluids based on their preferences and needs to maintain proper hydration and health. However, the documentation for March 2024 indicated numerous incomplete entries and instances where residents refused fluids. Interviews with staff, including a Medication Technician and the Director of Nursing, revealed that water should be passed every few hours and during medication pass, but there were times when this did not happen. The Director of Nursing was unaware of the residents' concerns about receiving water. This deficiency highlights a failure to adhere to the facility's hydration policy and ensure residents' hydration needs are consistently met.
Failure to Complete Timely Background Checks for CNAs
Penalty
Summary
The facility did not ensure thorough background checks were completed for two Certified Nursing Assistants (CNAs) prior to their hire. Specifically, CNA-C was hired without a Department of Justice (DOJ) letter and a Governmental Findings Report (GFR) until nearly a month after the hire date. Similarly, CNA-E was hired without these documents, which were only obtained over three months later. This failure to complete background checks in a timely manner is a violation of the facility's Abuse, Neglect, and Exploitation policy, which mandates that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before starting their job. The issue was identified during a survey where a sample of eight staff members was reviewed. The surveyor found that the background checks for CNA-C and CNA-E were not completed as required by state regulations. Interviews with facility staff, including the President of Success and the Scheduler, confirmed that the background checks were not conducted prior to the CNAs' start dates. The facility's Human Resources Support Center had conducted an audit and implemented a Performance Improvement Plan (PIP) to address the issue, but the deficiency still occurred, indicating a lapse in the facility's compliance with its own policies and state regulations.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility did not ensure an allegation of abuse was thoroughly investigated for one resident (R2). R2, who had intact cognition and was responsible for their own healthcare decisions, reported that a CNA was too rough during morning care, causing pain and discomfort. The facility's investigation was incomplete as it did not include a 5-day report to the State Agency, interviews with R2, other residents, and staff, or documentation that R2's physician was notified. Additionally, R2's ADLs and pain care plans were not reviewed or revised following the incident. The investigation summary indicated that the police were notified and conducted an onsite visit, concluding that no crime was committed. However, the facility failed to provide thorough documentation of the investigation, including interviews and notifications. The Director of Nursing and the President of Success confirmed that the necessary interviews and documentation were missing, and the 5-day investigation report was not located in the Misconduct Incident Reporting system. Furthermore, R2's care plans were not updated to include interventions to prevent or decrease pain during toileting.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedarburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lasata Care Center | 0 mi | — | 8 | 0 |
| Newcastle Place | 7.9 mi | — | 6 | 0 |
| Complete Care At Germantown | 8 mi | — | 0 | 0 |
| Samaritan Nursing And Rehab | 8.1 mi | — | 23 | 3 |
| Cedar Lake Health And Rehab Center | 8.2 mi | — | 2 | 0 |
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