Inspection Reports for Muskego Health and Rehabilitation Center

The inspection was conducted due to a complaint investigation involving alleged abuse, neglect, and medication errors at Muskego Health and Rehabilitation Center.

The facility failed to timely report an allegation of abuse involving a resident, did not follow wound care protocols including hand hygiene and use of proper PPE, and had medication administration errors where a resident missed multiple doses of prescribed medications.

The complaint involved an allegation of verbal abuse by an LPN toward Resident 1 (R1) on 10/8/25. The facility became aware of the allegation on the evening of 10/8/25 but did not report it to the state agency until 10/9/25 at 8:09 PM, exceeding the required 2-hour reporting timeframe. The investigation included interviews with R1, staff, and review of statements. The allegation was not witnessed by other staff but was reported by R1 and corroborated by a CNA who was told by R1. The LPN was suspended pending investigation.

The inspection was conducted due to complaints involving resident grievances about staff interactions and concerns regarding the provision of weekly showers for a resident.

The facility failed to resolve a grievance regarding a Certified Nursing Assistant (CNA-E) working with a resident despite documented concerns, and the resident received only one shower in the last 30 days despite facility policy requiring weekly showers.

The complaint involved a grievance filed by resident R1 about CNA-E's care and failure to follow grievance resolution procedures, and concerns that R1 did not receive weekly showers as required. The grievance was substantiated with findings that CNA-E continued to care for R1 despite the grievance and that R1 had only one shower in 30 days.

The inspection was conducted following a complaint survey related to pressure sores and the facility's failure to ensure proper use of bilateral heel protectors for residents with pressure injuries.

The facility failed to ensure that bilateral heel protectors were worn according to physician orders for one resident (R7), which had the potential to worsen existing heel sores and affect other residents with pressure sores. Documentation showed inconsistent use of heel protectors in March and April 2025, confirmed by the Director of Nursing.

The visit was complaint-related following a complaint survey after the facility's recertification in February 2025. The state survey agency cited the facility for pressure sores, and the facility had a plan of correction dated 03/19/25 with a desk revisit. The Director of Nursing confirmed ongoing documentation issues and recent efforts to improve audits and skin assessments.

The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, care and treatment, abuse prevention, infection control, and safety.

The facility was found deficient in multiple areas including failure to provide prior written notice for room changes, failure to notify physicians of significant weight loss, verbal abuse incidents not reported or investigated timely, inadequate wound care and assessments, failure to prevent elopement and falls, inaccurate nursing staff postings, and lapses in infection control practices.

The inspection was conducted based on complaints and allegations including failure to ensure residents are fully informed in a language they understand, failure to timely report suspected abuse or neglect, inadequate investigation of resident-to-resident altercations and neglect allegations, and failure to ensure adequate supervision and accident prevention for residents at risk of falls and smoking.

The facility failed to ensure meaningful communication with a non-English speaking resident, did not report allegations of neglect to the State Survey Agency, inadequately investigated resident-to-resident abuse and neglect allegations, and failed to thoroughly investigate multiple resident falls and revise care plans accordingly. Additionally, the facility did not ensure adequate supervision and safety measures for residents at risk of falls and smoking.

The complaint investigation included allegations that the facility did not ensure meaningful communication for a non-English speaking resident, failed to report neglect allegations to the State Survey Agency, did not thoroughly investigate resident-to-resident abuse and neglect allegations, and failed to ensure adequate supervision and accident prevention for residents at risk of falls and smoking. Some allegations were substantiated with findings of minimal harm and deficiencies in investigation and reporting.

The inspection was conducted due to allegations of neglect, abuse, and failure to provide appropriate care, including failure to report incidents and inadequate investigation of falls and other incidents.

The facility failed to timely report allegations of neglect, did not thoroughly investigate resident-to-resident altercations and falls, failed to provide appropriate care for pressure ulcers and colostomy, did not ensure proper medication administration and monitoring, lacked adequate infection control precautions, and did not maintain accurate staffing records including charge nurse designation and census posting.

The complaint investigation was triggered by allegations of neglect, abuse, failure to report incidents, inadequate investigation of falls and altercations, and failure to provide appropriate care and services.

The inspection was conducted due to complaints regarding failure to ensure professional standards of care in wound care order transcription and antibiotic administration, as well as failure to implement enhanced barrier precautions and proper infection control practices.

The facility failed to ensure physician wound care orders were properly transcribed and administered for antibiotics for one resident, and failed to document skin conditions during nursing assessments for another. Additionally, the facility failed to implement enhanced barrier precautions for residents with wounds, catheters, or gastrostomy tubes, and staff did not follow proper glove changing protocols during incontinence care, posing potential harm from infection transmission.

The complaint investigation revealed a transcription error occurred when a resident was readmitted from the hospital, resulting in missed antibiotic doses. The Director of Nursing confirmed the transcription error and a break in the system for transcribing wound care orders. The grievance log included concerns from a resident's Power of Attorney about missed medication orders.

The inspection was conducted due to a complaint investigation regarding an incident where resident R4 punched resident R7 during a church service on 07/23/2023, with concerns about lack of staff supervision and failure to protect residents from physical abuse.

The facility failed to protect one resident (R7) from physical abuse by another resident (R4) during an unsupervised church service. The incident involved R4 punching R7 in the arm, with minimal harm and no physical injury documented. The facility lacked adequate staff supervision to ensure R4 remained an arm's length away from other residents as required.

The complaint investigation found that R4 punched R7 in the arm during a church service on 07/23/2023 when staff were not present to supervise. The facility self-report and follow-up interviews indicated no physical injury or adverse psychosocial outcomes for R7. R4 was placed on 1:1 supervision after the incident. The investigation revealed lapses in staff supervision during the church service.

The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, discharge planning, infection control, room space, and other aspects of facility operations.

The facility was found deficient in multiple areas including call light accessibility, protection from abuse, timely transfer/discharge notifications, baseline and comprehensive care planning, discharge planning and summary, pressure ulcer care, fall prevention and investigation, psychotropic medication management, water management plan, and room space requirements.

The inspection was conducted to investigate complaints related to resident dignity and privacy during wound care, resident-to-resident abuse, failure to provide consistent bathing/showers, and inadequate pressure ulcer care.

The facility failed to ensure resident dignity and privacy during wound care, failed to protect a resident from resident-to-resident abuse, did not consistently provide bathing/showers to dependent residents, and did not provide appropriate pressure ulcer care including proper infection control and repositioning.

The complaint investigation focused on dignity/privacy violations during wound care for Resident 3, resident-to-resident abuse involving Residents 1 and 2, failure to provide consistent bathing/showers for Residents 3, 4, and 10, and inadequate pressure ulcer care for Resident 3.

The inspection was conducted as a recertification survey to assess compliance with regulatory requirements and evaluate the facility's care and safety practices.

The survey identified deficiencies including failure to provide appropriate pressure ulcer care for a resident with hand contractures, inadequate supervision and fall prevention measures for multiple residents, and failure to follow facility policies regarding mechanical lift transfers.