Cedarburg Health Services

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

47.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 45.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.78 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 50 beds and averages 45.1 residents a day — about 90% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.96 hrs/resident/day on weekends vs 4.47 on weekdays — 11% thinner on weekends. RN hours go from 1.03 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

• Potential for harm · D2025-01-23 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a physician was notified of blood sugar levels that were outside the ordered parameters for 1 resident (R) (R20) of 15 sampled residents. R20 had a diagnosis of diabetes and a physician's order that instructed staff to notify the physician if R20's blood sugar level was over 400 (milligrams/deciliter (mg/dL)). On 12/19/24, 12/23/24, and 1/3/25, R20's blood sugar level was over 400 mg/dL. R20's physician was not notified. Findings include: The facility's Change in Condition of the Resident policy, dated 9/20/22, indicates: Notifications that do not require immediate consultation with a physician may be made via phone, fax, or method preferred by the physician being contacted. The Center shall develop a method to track faxes sent to ensure timely response. On 1/22/25, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had a diagnosis of diabetes. R20's Minimum Data Set (MDS) assessment, dated 11/8/24, had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure adequate supervision during meals for 2 residents (R) (R24 and R10) of 8 sampled residents observed during mealtime. R24 had a diagnosis of dysphagia (difficulty swallowing). R24's care plan indicated R24 required full assistance with eating and should be cued to take one sip at a time and slow down. On 1/21/25, R24 was observed eating lunch in the dining room without staff assistance. In addition, staff removed R24 from the dining room after R24 coughed, drooled, and appeared to be in distress during the meal. R10's care plan indicated R10 had difficulty swallowing and contained interventions to remind R10 to swallow after each bite and take a drink after every 2-3 bites. On 1/21/25, R10 was observed eating lunch in the dining room without staff assistance. Findings include: During the survey, the facility indicated they do not have a policy related to dining assistance. 1. From 1/21/25 to 1/23/25, Surveyor reviewed R24's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-23 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 3 residents (R) (R13, R18, and R19) of 15 sampled residents. R13's physician order for fluticasone (a nasal spray) indicated not to keep fluticasone at the bedside. On 1/21/25, fluticasone was observed at R13's bedside. R18's medication administration record (MAR) did not accurately reflect the time polyethylene glycol (an osmotic laxative) was administered on 1/22/25. Staff administered hydralazine (a vasodilator medication used to lower blood pressure) to R19 on 1/22/25 prior to obtaining R19's blood pressure in accordance with the physician's order. In addition, R19's MAR did not accurately reflect the time polyethylene glycol was administered on 1/22/25. Findings include: The facility's Medication Administration Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medication are permitted to do so with a prescriber's order and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-23 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure it was free a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 30 opportunities which resulted in a 10% medication error rate that affected 1 resident (R) (R19) of 5 residents observed during medication administration. During medication administration observations for R19 on 1/22/25, staff did not administer Biofreeze menthol topical analgesic (a pain relieving treatment), cholecalciferol (a vitamin supplement), or levetiracetam (a seizure medication) as ordered. Findings include: 1. From 1/21/25 to 1/23/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including stroke with hemiplegia, hypertension, and seizure disorder. R19's most recent Minimum Data Set (MDS) assessment, dated 12/30/24, indicated R19 had moderate cognitive impairment. On 1/22/25 at 9:02 AM, Surveyor observed Registered Nurse (RN)-D prepare…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-23 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and record review, the facility did not ensure all drugs or biologicals were discarded when expired in 1 of 2 medication rooms in the facility. On 1/21/25, expired stock medications were observed in a cabinet and refrigerator in the 400 unit medication room. Findings include: The facility's Disposal of Medications, Syringes and Needles policy, dated 2007, indicates: .5. Dispose of discontinued medications within 90 days of the date the medication was discontinued .7. Outdated medications .shall be destroyed according to the above policy . On 1/21/25 at 11:06 AM, Surveyor and Director of Nursing (DON)-B observed medications stored in the medication room on the 400 unit and noted the following expired medications in the floor stock medication cabinet: ~ An unopened bottle of diphenhydramine HCL 25 milligram (mg) tablets with an expiration date of 10/2024 ~ An open bottle of diphenhydramine HCL 25 mg tablets with an expiration date of 6/2024 ~ An unopened bottle of loratadine 10 mg tablets with an expiration date of 10/2024 Surveyor and DON-B…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-23 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R9 and R15) of 4 sampled residents. R9 and R15 had symptoms of an upper respiratory infection and were not placed on precautions in a timely manner. Findings include: The facility's Transmission Based (Isolation) Precautions policy, revised 9/24/24, indicates: 1. Facility staff will apply transmission based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the Centers for Disease Control and Prevention (CDC) for transmission based precautions; airborne, contact, and droplet precautions. 9. Initiation of Transmission Based Precautions (Isolation Precautions): a. Nursing staff may…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-04 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff and resident interview, the facility did not ensure 2 residents (R) (R13 and R9) of 14 sampled residents had hot water in their bathrooms. During observations on 10/4/24, R13 and R9's bathroom sinks did not have hot water. Findings include: 1. On 10/4/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and diabetes mellitus. R13's Minimum Data Set (MDS) assessment, dated 8/24/24, stated R13's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R13 had intact cognition. R13's MDS assessment also indicated R13 required staff set up/supervision for oral hygiene and toileting and moderate assistance for bathing. R13's medical record indicated R13 was responsible for R13's healthcare decisions. On 10/4/24 at 9:21 AM, Surveyor entered R13's bathroom and tested the hot water. Surveyor noted there was no hot water in the sink. R13 was not in R13's room at the time. On 10/4/24 at…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-04 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure a grievance was thoroughly resolved for 1 resident (R) (R3) of 14 sampled residents. Resident Representative (RR)-H filed a grievance on behalf of R3 on 8/8/24 that indicated R3 experienced a delayed call light response time and was not attended to in a timely manner. The facility did not resolve the grievance in a timely manner. Findings include: The facility's Grievance Policy, with a revision date of 7/2022, indicates: When a complaint/grievance report is initiated: .The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. The facility's Call lights: Accessibility and Timely Response policy, with a revision date of 8/8/24, indicates: .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-04-04 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure fluids were provided on a consistent basis for 4 residents (R) (R3, R4, R5, and R6) of 4 sampled residents. R3, R4, R5 and R6 did not receive fresh drinking water on a consistent basis or in accordance with their nutritional assessment. Findings include: The facility's Hydration policy, with a review date of 7/26/22, indicates each resident should be offered sufficient fluids, to include water and other liquids, based on resident preferences and needs, to maintain proper hydration and health. This includes ensuring fluids are available and within reach. 1. R3 was admitted to the facility on [DATE] with diagnoses including morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus with diabetic neuropathy, chronic diastolic (congestive) heart failure, irritable bowel syndrome without diarrhea, and gastroesophageal reflux disease without esophagitis. R3's Minimum Data Set (MDS) assessment, dated 1/30/24,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-04 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and record review, the facility did not ensure thorough background checks were completed for 2 of 8 sampled staff. The facility did not ensure a Department of Justice (DOJ) letter and State of Wisconsin Department of Health Services (DHS) Governmental Findings Report (GFR) (formerly known as the Integrated Background Information System (IBIS) letter) were obtained for Certified Nursing Assistant (CNA)-C and CNA-E prior to hire. Findings include: The Wisconsin Background Check and Misconduct Investigation Program Manual by the Department of Health Services, revised January 2024, indicates: An entity is required to complete caregiver background checks on caregivers. At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents: 1. A completed DHS F-82064 (Background Information Disclosure) form. 2. A response from the DOJ, either ~A 'no record found' response or ~A criminal record transcript; and 3. A GFR from DHS that reports the person's status, including administrative finding or licensing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to NORTH SHORE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $428K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI