With a score of 30/100, Edenbrook Lakeside ranks in the bottom tier of Wisconsin nursing facilities, earning an F grade. CMS data highlights significant concerns that prospective residents and families should thoroughly evaluate.
Staffing at Edenbrook Lakeside is near the national average, with 3.59 total nursing hours per resident per day (national average: 3.8 hours).
Recent CMS inspections identified 31 deficiencies at Edenbrook Lakeside, including 2 classified as serious — among the most concerning citation levels. The most notable finding involved: provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including a.
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.59 | 3.8 | Average |
| Registered Nurses (RN) | 1.07 | 0.7 | Above Average |
| Licensed Practical Nurses (LPN) | 0.50 | 0.7 | Below Average |
| Certified Nursing Assistants (CNA) | 2.02 | 2.4 | Below Average |
| Weekend Total Nursing | 3.05 | 3.8 | Below Average |
| Weekend RN Hours | 0.68 | 0.7 | Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0623 Severity DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including aFeb 25, 2025 · Resident Rights Deficiencies
- Tag 0626 Severity DPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Feb 25, 2025 · Resident Rights Deficiencies
- Tag 0684 Severity DProvide appropriate treatment and care according to orders, resident’s preferences and goals.Oct 23, 2024 · Quality of Life and Care Deficiencies
- Tag 0698 Severity DProvide safe, appropriate dialysis care/services for a resident who requires such services.Oct 23, 2024 · Quality of Life and Care Deficiencies
- Tag 0656 Severity DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Oct 23, 2024 · Resident Assessment and Care Planning Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 4.6% | 4.5% | Average |
| Falls with major injury | 2.0% | 3.0% | Better |
| On antipsychotic medication | 12.1% | 14.5% | Better |
| Urinary tract infections | 1.3% | 2.5% | Better |
| ADL decline (daily activities) | 7.3% | 14.0% | Better |
| Excessive weight loss | 6.5% | 7.5% | Better |
| New/worsened incontinence | 25.7% | 45.0% | Better |
⚠️ Penalties & Fines
2 penalties recorded by CMS
Total fines: $138,434
How This Grade Was Calculated
This facility's grade of F is based on a score of 30 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 2★ → 16 pts (max 40)
- Health Inspection Rating: 2★ → 10 pts (max 25)
- Staffing Rating: 3★ → 12 pts (max 20)
- Quality Measures Rating: 4★ → 12 pts (max 15)
- Penalty deductions: -10 pts
- Fine deductions: -10 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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