Edenbrook LakesideCMS ratings, inspections and fines
- Address
- 2115 E Woodstock Pl, Milwaukee, WI 53202
- CCN
- 525319
- Ownership type
- For-profit, limited liability company
- Certified beds
- 145
- Chain
- Eden Senior Care
- Residents per day
- 91
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Edenbrook Lakeside an overall rating of 1 of 5 stars. The last standard survey was on 7 Apr 2026. The latest survey cycle has 23 health citations. The median for nursing homes in Wisconsin is 7. CMS lists 2 fines with a total of $138,434 for this home in its penalties file. CMS also lists 1 payment denial.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Milwaukee County median | Wisconsin median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 1 | 2.0 | 3.0 | 3.0 |
| Health inspection rating | 1 | 1.0 | 3.0 | 2.8 |
| Staffing rating | 3 | 3.0 | 4.0 | 2.9 |
| Quality measure rating | 3 | 3.0 | 3.0 | 3.6 |
A median is the middle value of the homes in the group: 32 homes in the county, 323 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Wisconsin median |
|---|---|---|---|
| Cycle 1 (latest) | 7 Apr 2026 | 23 | 7 |
| Cycle 2 | 24 Oct 2024 | 7 | 7 |
| Cycle 3 | No date | 13 | 6 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | K0 | L0 | |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 23 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 2 Jun 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint investigation | 30 Jun 2026 |
| 2 Jun 2026 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 30 Jun 2026 |
| 2 Jun 2026 | F0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | D | Complaint investigation | 30 Jun 2026 |
| 7 Apr 2026 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Complaint investigation | 4 May 2026 |
| 7 Apr 2026 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | J | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 30 Jun 2026 |
| 7 Apr 2026 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint investigation | 4 May 2026 |
| 7 Apr 2026 | F0761 | 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. | E | Standard survey | 4 May 2026 |
| 7 Apr 2026 | F0826 | Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | E | Complaint investigation | 4 May 2026 |
| 7 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 30 Jun 2026 |
Survey cycle 2: 7 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 26 Feb 2025 | F0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Complaint investigation | 19 Mar 2025 |
| 26 Feb 2025 | F0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | D | Complaint investigation | 19 Mar 2025 |
| 24 Oct 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint investigation | 18 Nov 2024 |
| 24 Oct 2024 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint investigation | 18 Nov 2024 |
| 24 Oct 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 18 Nov 2024 |
| 24 Oct 2024 | F0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard survey | 18 Nov 2024 |
| 24 Oct 2024 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint investigation | 18 Nov 2024 |
Survey cycle 3: 13 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 27 Mar 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint investigation | 29 Mar 2024 |
| 27 Mar 2024 | F0760 | Ensure that residents are free from significant medication errors. | D | Complaint investigation | 29 Mar 2024 |
| 24 Jan 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint investigation | 5 Mar 2024 |
| 24 Jan 2024 | F0711 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | E | Complaint investigation | 22 Feb 2024 |
| 10 Jan 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | 5 Mar 2024 |
| 6 Dec 2023 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint investigation | 2 Jan 2024 |
| 6 Dec 2023 | F0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J | Complaint investigation | 2 Jan 2024 |
| 19 Sep 2023 | F0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Standard survey | 17 Oct 2023 |
| 19 Sep 2023 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint investigation | 17 Oct 2023 |
| 19 Sep 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Complaint investigation | 17 Oct 2023 |
| 19 Sep 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | 17 Oct 2023 |
| 19 Sep 2023 | F0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard survey | 17 Oct 2023 |
| 19 Sep 2023 | F0761 | 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. | E | Standard survey | 17 Oct 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 10 Jan 2024 | Fine | $59,813 | |
| 10 Jan 2024 | Payment denial | 11 | |
| 6 Dec 2023 | Fine | $78,621 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Wisconsin median | Wisconsin average (CMS) |
|---|---|---|---|
| All nurse staff | 3.43 | 4.00 | 4.21 |
| Registered nurses (RN) | 1.02 | 0.90 | 0.99 |
| Licensed practical nurses (LPN) | 0.38 | 0.64 | |
| Nurse aides | 2.02 | 2.58 | |
| All nurse staff, weekends | 2.89 | 3.60 | 3.77 |
- Nurse staff turnover in a year
- 41.4%
- Nurse staff turnover, Wisconsin median
- 46.2%
- RN turnover in a year
- 10.0%
- Administrators who left in a year
- 1
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Wisconsin median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 6.7% | 15.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 1.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.9% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.6% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 13.3% | 16.8% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.2% | 4.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 11.4% | 14.4% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- For-profit, limited liability company
- Legal business name
- Lake Terrace Nursing and Rehab LLC
- Chain
- Eden Senior Care (21 homes in the CMS chain file)
The CMS ownership record of this home lists no organisation.
The site shows organisations only. It does not show the names of persons.
Other homes in Milwaukee County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Saint Johns on the Lake | Milwaukee | 4 of 5 | 7 | $0 | 3 Jun 2025 | |
| Milwaukee Catholic Home | Milwaukee | 4 of 5 | 2 | $0 | 20 May 2026 | |
| Eastcastle PL Bradford Ter Conv Ctr | Milwaukee | 5 of 5 | 13 | $90,278 | 18 Feb 2026 | |
| Jewish Home and Care CenterSpecial Focus candidate | Milwaukee | 1 of 5 | 19 | $8,959 | 6 Apr 2026 | |
| Milwaukee Health and Rehab | Milwaukee | 4 of 5 | 3 | $0 | 8 Dec 2025 | |
| Mercy Health Services | Milwaukee | 3 of 5 | 6 | $47,753 | 21 May 2025 | |
| St Ann Health and Rehabilitation Center | Milwaukee | 4 of 5 | 8 | $0 | 5 Mar 2026 | |
| Bayshore Nursing & RehabSpecial Focus candidate | Glendale | 1 of 5 | 43 | $0 | 30 Sep 2025 | |
| Wheaton Franciscan HC - Terrace at St Francis | Milwaukee | 1 of 5 | 26 | $219,651 | 20 Aug 2025 | |
| Complete Care at Glendale West | Glendale | 3 of 5 | 17 | $11,180 | 22 May 2025 | |
| St Francis Health Services | Saint Francis | 3 of 5 | 8 | $0 | 18 Feb 2026 | |
| Aria at Mitchell Manor | West Allis | 3 of 5 | 7 | $15,872 | 29 Jan 2025 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Edenbrook Lakeside (CCN 525319). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/edenbrook-lakeside-milwaukee-wi-525319/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Edenbrook Lakeside last inspected?
- The latest inspection with a citation in the CMS record was on 2 Jun 2026. It was a complaint investigation. It gave 3 citations. The standard survey before the last one was on 24 Oct 2024.
- Who operates Edenbrook Lakeside?
- The CMS record gives the ownership type as for-profit, limited liability company. CMS lists the home in the chain Eden Senior Care. The CMS ownership file names no organisation for this home. This site does not show the names of persons.
- Is Edenbrook Lakeside a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 2 homes in Wisconsin as Special Focus Facilities and 10 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.