Muskego Health: Infection Control Failures - WI
Federal inspectors at Muskego Health and Rehabilitation Center discovered the nursing assistant assigned to the resident had no documentation of providing required incontinence care every two hours on January 8 and 9. When the family member arrived at the facility and walked past staff in the hallway, they found the resident needed to be changed and required a new gown.
The certified nursing assistant told inspectors she met the family member in the hallway, walked to the room together, and then helped provide care. But she noted she wouldn't have documented the task since the resident wasn't assigned to her.
Staff told the family member the facility phone showed no missed calls that night. The administrator initially claimed staff were doing rounds and had verified this, but when pressed by inspectors, admitted no one had actually checked the phone records.
This incident exemplified broader care failures inspectors documented across multiple areas of the 39-bed facility during their January 27, 2025 visit.
Infection Control Breakdown
The most serious violations involved infection prevention. Staff performed wound care on residents without following basic safety protocols required for patients with open wounds and medical devices.
Licensed Practical Nurse LPN-F provided wound care to a hospice patient with multiple pressure ulcers while wearing only gloves. When inspectors asked if the resident was on any precautions, the nurse said no. A hospice aide assisting with the care noted she had worked there two weeks and no one had mentioned any special requirements.
The facility's policy requires Enhanced Barrier Precautions for all residents with wounds or indwelling medical devices like catheters. Staff must wear gowns and gloves during "high-contact" activities including wound care, bathing, transferring, and device care.
But inspectors found chaos in the system. Eleven residents were listed as needing Enhanced Barrier Precautions, yet only five rooms had the required signs posted on doors. Meanwhile, 17 residents actually qualified for the precautions based on their medical devices and wounds.
One resident with both an indwelling urinary catheter and a wound received care from staff who didn't know isolation gowns were stored in the first closet inside the room door. The nurse thought gowns were kept in a linen room down the hallway.
A certified nursing assistant told inspectors there were no residents "in isolation" while standing in a hallway where six rooms should have had precaution signs posted.
Director of Nursing DON-B, who also served as the facility's infection preventionist, acknowledged the problems. She told inspectors she had gone through the facility the day before the inspection and posted signs on doors that needed them, planning to fix the remaining rooms.
Missed Treatments for Dying Patient
A hospice patient with severe cognitive impairment didn't receive wound care for his lower back pressure ulcer 20 days out of 71 days between October 2024 and January 2025.
The wound grew from 1 x 3 x 0.1 centimeters in October to 6 x 4 x 0.5 centimeters by January — a sixfold increase in surface area. Treatment records showed gaps throughout:
October: 8 missed days out of 27 November: 3 missed days out of 21 December: 6 missed days out of 13 January: 3 missed days out of 10
The Director of Nursing acknowledged being aware of the missing treatments but said she saw no documentation explaining why wound care wasn't provided. She noted the facility tried to address larger pressure ulcers causing the most pain, while other areas "should just be monitored."
Inspectors observed multiple purple discolorations on the patient's feet and heels that weren't documented anywhere in medical records.
Inadequate Fall Investigations
Five residents experienced falls that weren't properly investigated, with staff failing to interview witnesses or determine when residents were last checked.
One resident with paraplegia fell from bed on October 29, 2024. The investigation documented "no statements found" and provided no information about when the resident was last seen. The root cause analysis determined he "rolled from bed" and recommended education about using the call light, but this intervention was never added to his care plan.
Another resident fell on January 5, 2025, while attempting to transfer back into bed. Again, no staff statements were obtained and no information documented about when she was last checked or toileted.
Licensed Practical Nurse LPN-L, who responded to one fall, couldn't recall which nursing assistant found the resident on the floor, whether the call light was on, or when the resident was last seen. When asked about fall investigation procedures, she said "I'm not sure about that" regarding whether staff had guidance packets to follow.
The facility had fall investigation checklists that required staff interviews and stated "complete all interviews with staff using the note section," but these weren't being used consistently.
Medication and Care Failures
A dialysis patient missed five doses of Epoetin Alfa injection over nine days because the medication wasn't available. Staff documented the drug was "on order," then "not available," then "pending delivery," but there was no evidence anyone contacted the physician or pharmacy about the problem.
Another resident admitted with a colostomy in October 2024 didn't receive physician orders for colostomy care until January 7, 2025 — 10 weeks later. The facility's policy requires licensed nurses to provide ostomy care "under the orders of the attending physician" with specific instructions about equipment type and change frequency.
A stroke patient with contractures was supposed to wear a splint on his right hand for six hours daily, but staff failed to document this care 30 times over six months. Occupational therapy notes revealed the patient wasn't tolerating the splint and had been switched to a palm guard, but nursing staff weren't informed of the change.
Systemic Problems
The violations reflected deeper organizational failures. The facility didn't designate charge nurses on daily schedules and failed to include required census numbers on staffing posts. Monthly infection rates weren't calculated or reported to quality committees.
Two residents consented to receive influenza and pneumonia vaccines but never received them, despite facility policies requiring these immunizations be offered.
A resident who needed dialysis three times weekly had no physician orders specifying the schedule, no care plan for monitoring complications, and only one partially completed communication form with the dialysis center out of six treatment sessions.
The inspection found a facility struggling with basic care coordination, where policies existed but weren't consistently followed, and where staff lacked awareness of fundamental infection control requirements for vulnerable residents.
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
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MUSKEGO HEALTH AND REHABILITATION CENTER in MUSKEGO, WI was cited for violations during a health inspection on January 27, 2025.
When the family member arrived at the facility and walked past staff in the hallway, they found the resident needed to be changed and required a new gown.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.