The discovery on January 9 exposed a pattern of neglect that extended far beyond one resident's room. State inspectors found the facility failed to investigate falls properly, left smoking supplies with a resident who needed supervision, and documented almost no care tasks for days at a time.
The family member had been calling the facility overnight but got no response. When they arrived at the nursing home, they met a certified nursing assistant in the hallway who claimed she couldn't recall the phone ringing. The CNA walked with the family member to the room, where they found the resident needed to be changed and required a new gown.
"The family member was trying to tell them how to do cares because it was how the family member wanted it done," the CNA later told inspectors.
Records showed the resident, identified as R235, had no documented incontinence care on January 8 or January 9. The facility's own tracking system contained only two entries for bowel and bladder care during a three-day period — both on January 5 at 6:00 AM and 7:00 AM.
Director of Nursing DON-B told inspectors there was no other documentation for incontinence or hygiene care that could be found.
When the nursing home administrator was questioned about how staff verified they were making required rounds, the administrator said they would have to look and see. The licensed practical nurse on duty claimed there were no missed calls on the phone that night but admitted never actually checking.
The CNA who was supposed to be caring for the resident during the overnight shift was no longer employed at the facility and unavailable for interview.
Resident Punched Roommate, Investigation Missed Key Details
Two weeks earlier, the facility bungled the investigation of a violent altercation between roommates. On December 14, R30 entered the bathroom while roommate R7 was trying to use it. What happened next revealed serious gaps in the facility's incident response.
The official report described an accidental collision where "R30's hand connected with R7's shoulder" as both residents moved around the bathroom at the same time.
R7 told a different story to inspectors. The resident, who has bilateral lower leg amputations and uses a wheelchair, said R30 was in his bed when he returned from the shower room. R30 got out of the bed and "hit R7 in the left shoulder with a fist," R7 reported.
R7 described ongoing problems with R30 going through his belongings and trying to wear his clothes. "R7 told R30 that if R30 keeps touching R7's clothes, R7 would cut R30's hands off," the inspection report states.
The facility's investigation included no interviews with other residents or staff who might have witnessed events. Licensed Practical Nurse LPN-C, who was called in to file the incident report, spoke only with two nurses on shift. She told inspectors R30 was easily redirected and had no history of hitting.
But R7 reported R30 continued entering his room even after being moved to different quarters. "R30 was last in R7's room yesterday," R7 told inspectors in January, with his new roommate confirming the intrusion.
Five Falls, Minimal Investigations
The facility's approach to fall investigations followed a similar pattern of incomplete documentation and missing interviews.
When R29 was found on the floor next to her bed on August 31, nursing staff documented she "just fell" and denied hitting her head. The investigation included no staff interviews to determine when she was last checked or what the environment looked like when she was discovered.
The care plan wasn't revised until September 3 — three days later.
R23 fell out of bed on October 29. The progress note stated "resident fell out of the bed he denied any complaints of pain." The fall investigation form showed "no statements found" under the category for staff interviews. No information was documented about when the resident was last seen.
"Resident was last rounded on around 6am," the investigation noted, but included no statements explaining where this timeframe came from.
R31's January 5 fall investigation also contained no staff statements. The resident was found on the floor "attempting to transfer back into bed" but investigators documented no information about when she was last checked or toileted.
Licensed Practical Nurse LPN-L described the facility's informal approach: "CNA's give statements. They usually give verbal statements."
But the inspection revealed a fall checklist in a nursing station binder that required written staff interviews. The checklist specifically instructed: "Complete all interviews with staff using the note section. State who and when you took their statement."
None of the fall investigations followed these written procedures.
Smoking Supplies Left Unsecured
R29's case illustrated another safety failure. An August 13 smoking evaluation determined she could not light cigarettes independently and required supervision while smoking. The assessment specified that the facility should store her lighter and cigarettes.
Five months later, R29 told inspectors her smoking supplies were in her purse in her room. Multiple staff members confirmed R29 had her own smoking supplies and needed supervision while smoking, but no care plan existed for her smoking needs.
The facility's smoking policy required that "smoking materials of residents requiring supervision with smoking will be maintained by facility staff" and stored in a locked wall box at the nurses' station.
R29 wasn't even listed on the facility's roster of residents who smoke.
Pattern of Incomplete Care Documentation
The documentation failures extended beyond individual incidents. When inspectors requested R235's task documentation for a 30-day period, they found no entries indicating incontinence care had been provided every two hours as required.
The facility's accident prevention policy, updated in December 2029, required identifying hazards, evaluating risks, implementing interventions, and monitoring effectiveness. But fall investigations consistently omitted basic information about environmental conditions, staff observations, and intervention implementation.
When R12 fell reaching for mints on his bedside table in November, the investigation identified "poor lighting" as a contributing factor but added no lighting interventions to his care plan.
The licensed practical nurse who responded to R12's fall couldn't recall which certified nursing assistant found the resident on the floor, whether the call light was within reach, or what time R12 was last seen before falling.
"I'm not sure about that," LPN-L told inspectors when asked if staff had access to fall investigation packets, despite the existence of detailed checklists in the nursing station.
The inspection found violations affecting the facility's ability to ensure residents remained free from accident hazards and received adequate supervision. The family member's discovery of their unchanged loved one represented just one example of care that fell short of basic standards, leaving residents vulnerable to neglect in a system designed to protect them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Muskego Health and Rehabilitation Center from 2025-01-27 including all violations, facility responses, and corrective action plans.
Additional Resources
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