Edenbrook Lakeside
Milwaukee, Wisconsin · CCN 525319
47 surveys since 2010, 38 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 293
- Surveys
- 47
- Harm or worse
- 38
- Immediate jeopardy
- 25
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 145
- Ownership
- For profit - Limited Liability company
- Chain
- EDEN SENIOR CARE
- County
- Milwaukee
- Medicare-certified since
- 1982
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 3
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 15 for-profit facilities with 128 or more beds in Wisconsin.
Last survey on record
Jun 2, 2026
160 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.43 | 3.71 |
| Registered-nurse hours per resident day | 1.02 | — |
| Annual nurse turnover | 41.4% | 58.8% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $138,434 across 2 penalties
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J35.6% | K— | L— |
| Actual harm | G23.7% | H— | I— |
| No harm, potential for more than minimal | D3768.5% | E1018.5% | F11.9% |
| No harm, potential for minimal | A— | B— | C11.9% |
Most frequently cited here
In CMS’s current monthly file.
- F6865×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F6844×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6563×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6232×
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
In the surveyor’s words
From the most serious findings on record at Edenbrook Lakeside, in the surveyor’s own words.
- Immediate jeopardy, isolatedF686Apr 7, 2026
Based on observation, interview, and record review, the facility did not ensure residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 7 of 8 residents (R2, R11, R15, R47, R74, R85, and R105) reviewed for pressure injuries. *R2 was admitted to the facility without any pressure injuries (PIs) and was assessed to be at risk for PIs. R2 developed an unstageable PI to the sacrum. The facility failed to implement an air mattress and implement a turning and repositing program prior to sacrum pressure injury development. The sacrum PI became infected requiring intravenous antibiotics and a 2-week hospitalization. […]
- Immediate jeopardy, isolatedF600Dec 6, 2023
Based on observation, interviews, and record review, the facility failed to ensure 1 of 1 resident (R16) reviewed for abuse was free from sexual abuse. The facility did not ensure R16 was free from sexual abuse by another resident (R17.) On 12/01/23, R17 was found in R16's room by a CNA. R17 was on top of R16; R16's gown was pulled up over her abdomen, R16's brief was torn, and R17's hand was observed moving back and forth on R16's vagina. R17 had also engaged in fondling R16's breasts and sucking on her nipples. R16 had activated her call light and shouted for assistance 16 minutes prior to staff responding and removing R17 from R16's room. The facility's failure to keep R16 safe from sexual abuse created a finding of immediate jeopardy that began on 12/1/23. […]
- Immediate jeopardy, isolatedF678Dec 6, 2023
Based on record review and interview, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR) to a resident who required emergency care for 1 (R6) of 3 residents reviewed for CPR. The facility currently has 73 out of 98 residents who desire CPR (Full Code). R6 was a full code (wanted CPR) and was found pulseless and nonbreathing on [DATE]. An LPN (Licensed Practical Nurse) failed to initiate CPR when R6 was found to be pulseless and not breathing. […]
- Immediate jeopardy, isolatedF678May 19, 2021
Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 2 (R1 & R2) of 3 residents reviewed, in accordance with the resident's advance directives. This deficient practice has the potential to affect 48 of 75 residents residing at the facility whom were full code and desired CPR per their advance directives. - On [DATE] R2 was found by nursing staff to be pulseless and not breathing. Nursing staff did not initiate CPR despite R2's advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - On [DATE] R1 was found by nursing staff to be pulseless and not breathing. Nursing staff did not initiate CPR despite R1's advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]
- Immediate jeopardy, isolatedF684May 19, 2021
Based on record review and interview, the facility did not ensure that 1 (R1) of 3 sampled residents received assessment and appropriate medical care when R1 experienced a significant change in her medical condition and complained about chest pain, difficulty breathing and not feeling well. The licensed practical nurse (LPN) did not collect data and did not ensure an RN assessment of a resident experiencing a significant change in condition. These failures created a finding of Immediate Jeopardy beginning on [DATE]. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy finding on [DATE] at 11:10 a.m. The facility removed the immediacy on [DATE] with the implementation of their action plan. […]
Read 55 findings in full →The most serious and the most recent: 55 of 293 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 19, 2026Complaint2 findings · 1 harm
- Jun 2, 2026Complaint3 findings · 1 harm
- Apr 7, 2026Standard and complaint20 findings · 1 harm
- Feb 26, 2025Complaint2 findings
- Oct 24, 2024Standard and complaint5 findings
- Mar 27, 2024Complaint2 findings
- Jan 24, 2024Complaint2 findings · 1 harm
- Jan 10, 2024Complaint1 finding
Show the 39 earlier surveys
- Dec 6, 2023Complaint2 findings · 2 harm
- Sep 19, 2023Standard and complaint6 findings
- May 25, 2022Standard and complaint11 findings
- Mar 1, 2022Complaint1 finding
- Jan 28, 2022Complaint2 findings · 1 harm
- Oct 27, 2021Complaint2 findings · 1 harm
- Jul 19, 2021Complaint3 findings · 1 harm
- May 19, 2021Complaint2 findings · 2 harm
- Feb 11, 2021Standard and complaint10 findings · 2 harm
- Oct 23, 2020Infection control1 finding · 1 harm
- Sep 2, 2020Complaint1 finding
- Jan 21, 2020Complaint4 findings · 3 harm
- Dec 17, 2019Complaint1 finding
- Sep 18, 2019Complaint2 findings
- Aug 27, 2019Complaint3 findings
- Jul 17, 2019Standard and complaint28 findings · 3 harm
- Feb 21, 2019Complaint2 findings
- Nov 20, 2018Complaint3 findings
- Aug 21, 2018Standard and complaint10 findings
- Mar 29, 2018Complaint9 findings · 2 harm
- Jun 20, 2017Standard and complaint23 findings
- Jan 26, 2017Complaint2 findings
- Mar 9, 2016Standard24 findings
- Jul 14, 2015Complaint1 finding
- Feb 17, 2015Complaint1 finding
- Dec 8, 2014Standard and complaint3 findings
- Jul 17, 2014Standard and complaint6 findings
- Jan 21, 2014Standard and complaint5 findings · 2 harm
- Jun 5, 2013—21 findings · 1 harm
- Mar 27, 2013—2 findings
- Feb 25, 2013—3 findings · 1 harm
- Nov 13, 2012—13 findings · 1 harm
- Oct 10, 2012—4 findings
- Jun 7, 2012—6 findings
- Jan 5, 2012—15 findings · 3 harm
- Aug 19, 2011Complaint11 findings · 7 harm
- Jun 9, 2011—1 finding
- Apr 6, 2011—9 findings · 1 harm
- Dec 14, 2010—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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