Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Cedarburg Health Services
Cedarburg, WI · 50 certified beds · Last Life Safety survey April 29, 2026
CMS Certification Number 525578 · first certified July 1995
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
13 citations — more than 29% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys on file averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 7 months from now. This facility’s last Life Safety survey was April 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 519 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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Emergency preparedness
2 of the 13 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 29, 2023 | 4 |
| January 23, 2025 | 7 |
| April 29, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0221 | Provide rooms that can be unlocked from inside without a key. | 1 | 2025-01-23 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2023-11-29 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-11-29 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2025-01-23 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-11-29 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-01-23 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2026-04-29 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2025-01-23 |
What the citations cover
- Smoke Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Miscellaneous Deficiencies 2
- Egress Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 29, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 22, 2026) |
January 23, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (February 17, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 14, 2025) |
| K-0221 | Provide rooms that can be unlocked from inside without a key. | Deficient, Provider has date of correction (January 24, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 30, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 5, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 28, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (January 28, 2025) |
November 29, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 29, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 29, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.