Wisconsin Nursing Facility Documented for Multiple Care Deficiencies Including Incomplete Investigations and Missed Treatments
MUSKEGO, WI - A January 2025 inspection at Muskego Health Care Center identified multiple areas where the facility did not ensure residents received adequate care and supervision, including incomplete fall investigations, missed wound treatments, and lapses in infection control protocols affecting the facility's 39 residents.
Inadequate Fall Investigation Procedures
Federal inspectors documented a pattern of incomplete fall investigations affecting multiple residents. When residents experienced falls, facility staff did not consistently gather essential information needed to prevent future incidents or implement appropriate safety measures.
In one case, a resident experienced an unwitnessed fall from bed on November 24, 2024, while reaching for mints on a bedside table. The inspection revealed that critical sections of the fall investigation template were left blank, including the resident's mental status at the time of the fall, whether the call light was within reach, and predisposing physiological factors. Although poor lighting was identified as an environmental factor contributing to the fall, no lighting-related interventions were added to the resident's care plan.
Another resident had a fall on August 31, 2024, discovered by a certified nursing assistant. The facility's investigation documentation stated "no statements found," meaning no written accounts were obtained from staff members about when the resident was last checked or what the room environment looked like at the time of discovery. The care plan was not revised until three days after the fall occurred.
When a resident with paraplegia fell on October 29, 2024, the investigation similarly lacked staff statements and documentation about when the resident was last seen. Despite the facility's policy requiring detailed evaluation and analysis of fall circumstances, including interviewing staff and examining trends such as time of day and location, these critical steps were not consistently completed.
Falls in nursing facilities represent a significant safety concern. According to the Centers for Disease Control and Prevention, approximately 1,800 older adults living in nursing facilities die each year from fall-related injuries. Thorough fall investigations serve multiple purposes: they help identify immediate hazards that need correction, reveal patterns that might indicate systemic problems, and provide information necessary to develop effective prevention strategies tailored to individual residents.
Complete investigations should document when the resident was last observed, what activities preceded the fall, environmental conditions, whether assistive devices were available and used properly, and the resident's physical and cognitive state. Staff interviews provide crucial context that medical records alone cannot capture. Without this information, facilities cannot determine root causes or implement targeted interventions to prevent recurrence.
Inconsistent Wound Care Treatment
Inspectors identified significant gaps in wound treatment for a resident receiving palliative care. The resident had an unstageable pressure ulcer on the lower back that measured 1 x 3 x 0.1 centimeters when first documented in October 2024. By January 2025, the wound had increased to 6 x 4 x 0.5 centimeters—a substantial expansion over 14 weeks.
Review of the resident's treatment records revealed the wound care was not provided as ordered on 20 separate occasions between October 2024 and January 2025. In October, the resident missed 8 out of 27 scheduled treatments. In November, 3 out of 21 treatments were not provided. December records showed 6 of 13 treatments were missed, and in January, 3 of 10 treatments were not completed. The facility's documentation did not explain why treatments were skipped.
Additionally, during observation of the resident, inspectors noted multiple small purple discolorations on areas over bony prominences—locations where pressure ulcers commonly develop. These areas were not documented in the resident's medical record, meaning they were not being monitored for potential progression to open wounds.
Pressure ulcers develop when sustained pressure on the skin reduces blood flow to tissues, causing damage and cell death. Consistent treatment is fundamental to healing because it maintains a clean wound environment, protects against infection, and promotes tissue regeneration. Missing even a few treatments can significantly delay healing or cause deterioration.
The progression from a 1 x 3 centimeter wound to a 6 x 4 centimeter wound represents a six-fold increase in surface area. Larger wounds take exponentially longer to heal, increase infection risk, cause greater pain, and require more intensive treatment. For patients receiving palliative care, effective wound management is particularly important for comfort and quality of life, even when cure is not the primary goal.
Undocumented skin discolorations represent missed opportunities for early intervention. Identifying and monitoring areas of skin compromise before they become open wounds allows for preventive measures such as repositioning schedules, pressure-relieving devices, and enhanced nutrition support.
Dialysis Care Coordination Failures
A resident admitted to the facility requiring hemodialysis three times weekly did not have physician orders documenting the dialysis schedule, monitoring requirements, or care protocols. The facility's policy requires specific orders including the type of vascular access, dialysis schedule, nephrologist contact information, transportation arrangements, and any medication adjustments needed before dialysis.
The facility also did not establish a care plan addressing dialysis-related needs and potential complications. Assessments before and after dialysis sessions were not consistently documented. Of the six dialysis sessions that should have occurred during the inspection lookback period, only one partially completed communication form was provided to surveyors.
Hemodialysis is a complex medical procedure that removes waste products and excess fluid from blood when kidneys can no longer perform this function adequately. Residents receiving dialysis face numerous risks including blood pressure changes, electrolyte imbalances, infection at the vascular access site, and fluid overload or depletion.
Proper monitoring before dialysis sessions helps identify issues that might affect treatment safety, such as signs of infection, changes in weight indicating fluid retention, or cardiovascular instability. Post-dialysis monitoring detects complications like excessive bleeding from the access site, blood pressure drops, or adverse reactions to the procedure.
The facility's agreement with the dialysis center specifically requires providing all necessary information before each treatment to ensure safe and appropriate care. Without documented communication, the dialysis facility cannot know about recent changes in the resident's condition, new medications, or other factors that might affect treatment parameters.
Infection Control and Safety Protocols
The inspection identified substantial deficiencies in the facility's infection prevention program. Enhanced Barrier Precautions, which require staff to wear gowns and gloves during high-contact care for residents with wounds or indwelling medical devices, were not properly implemented.
Of 17 residents who qualified for Enhanced Barrier Precautions based on having wounds, urinary catheters, feeding tubes, ostomies, or dialysis access, only 5 had the required signage posted on their doors. One room had a sign posted despite the resident not meeting criteria for these precautions.
Staff members interviewed during the inspection demonstrated inconsistent knowledge about which residents required precautions and where protective equipment was located. When one nurse performed wound care on a resident with multiple pressure ulcers, the nurse wore only gloves despite facility policy requiring both gown and gloves during wound care.
The facility also did not maintain documentation of monthly infection rates by type, making it impossible to identify trends or target prevention efforts effectively. The Director of Nursing, who also served as Infection Preventionist, stated they monitored for infections by reviewing new antibiotic orders but did not maintain a systematic surveillance system or calculate rates that would allow comparison across time periods.
Enhanced Barrier Precautions were developed specifically to reduce transmission of multidrug-resistant organisms in nursing facilities. These organisms can spread through contact with contaminated surfaces, equipment, or healthcare workers' hands and clothing. Residents with wounds or indwelling devices face elevated colonization risk because these create entry points for bacteria.
High-contact care activities—including dressing changes, bathing, transferring, and device care—create multiple opportunities for transmission. Gowns protect healthcare workers' clothing from contamination and prevent transfer of organisms to subsequent patients. The combination of gowns and gloves during these activities has been shown to reduce transmission rates when implemented consistently.
Without proper signage, staff cannot know which residents require enhanced precautions, leading to inconsistent application. When some staff members are unaware of precaution requirements or cannot locate protective equipment readily, the entire system breaks down. Effective infection prevention requires not just having policies in place, but ensuring all staff understand and can implement them correctly.
Additional Issues Identified
The facility did not designate charge nurses on daily nursing schedules for a six-month period, making it unclear who held supervisory responsibility during each shift. Daily nurse staffing postings did not include the facility census as required by federal regulations, preventing verification that staffing levels were appropriate for the number of residents.
One resident with multiple sclerosis requiring mechanical lift assistance for transfers was reportedly assisted by a residential aide from the facility's community-based residential unit who was not certified or trained to provide care to nursing home residents. The residential aide position description did not include authority to assist with nursing home resident care.
A resident with hemiplegia following stroke had a physician order for a hand splint to be worn six hours daily to prevent contracture progression. Documentation showed 30 instances over six months when staff did not record whether the splint was applied. During multiple survey observations over two days, the resident was not wearing the ordered splint. The occupational therapy department had changed the resident's device from a splint to a palm guard based on comfort and tolerance, but the physician order and care plan were never updated to reflect this change.
Medication administration issues affected two residents. One resident who consented to receive influenza vaccination did not receive it despite no documented contraindications. Another resident consented to pneumococcal vaccination but did not receive it, with no physician orders placed to obtain the vaccine. A third resident had five doses of Epoetin Alfa, a medication for anemia, missed because the medication was not available at the facility, with no documentation that the physician or pharmacy were contacted about the unavailable medication.
A resident admitted with a colostomy did not have physician orders for colostomy care for ten weeks after admission. The facility's policy requires orders specifying the type of ostomy, frequency of appliance changes, and equipment needed. Treatment documentation for colostomy care during this period was minimal.
Pharmacy medication review recommendations for one resident went unaddressed for months. In September 2024, the pharmacist recommended changes to simplify the resident's medication schedule and ensure proper documentation of as-needed medications. The same recommendations were repeated in November 2024. The facility did not act on these recommendations until January 27, 2025—the day surveyors requested to see signed pharmacy review forms.
The facility did not maintain documentation showing it had reviewed and calculated monthly infection rates, a core component of effective infection surveillance. Without systematic tracking of infection types, locations, and trends, facilities cannot identify emerging problems or evaluate whether prevention strategies are working.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Muskego Health Care Center from 2025-01-27 including all violations, facility responses, and corrective action plans.
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