The delayed reporting at Muskego Health and Rehabilitation Center meant the nursing assistant remained on duty for days after multiple witnesses heard the abuse. Federal inspectors found the facility violated reporting requirements in three separate cases involving verbal abuse and missing money.
Two certified nursing assistants witnessed CNA-H call a resident with severe dementia "dumb" in the dining room. A hospice worker heard the same nursing assistant call the resident "oh this bitch" during a transfer. All three staff members admitted they failed to report the incidents immediately.
The resident targeted in these incidents has Alzheimer's disease and scored a 3 on cognitive testing, indicating severely impaired decision-making abilities. The resident requires substantial assistance with dressing and mobility and is incontinent.
On February 11, a different resident began crying uncontrollably around 9:30 AM. Licensed Practical Nurse LPN-E documented that the resident, who communicates through head nods and cue cards after a brain hemorrhage, could not explain the distress. When staff asked if CNA-H was being "mean and rough," the resident nodded yes and requested a different caregiver.
Despite this complaint, administrators allowed CNA-H to work the entire shift until 1:30 PM. LPN-E witnessed CNA-H enter the crying resident's room at 11:40 AM, even after the abuse allegation. The investigation didn't begin until after CNA-H left the building.
"LPN-E felt humiliated" when CNA-H "started bobbing CNA-H's head and laughing at LPN-E" while leaving work that day, according to inspection records.
The facility's investigation revealed the pattern of unreported abuse. During questioning about the February 11 incident, administrators discovered that staff had witnessed CNA-H verbally abusing the dementia patient weeks earlier but never reported it.
Administrator NHA-A told inspectors: "NHA-A is upset with all the staff because they knew better and should have reported."
A third reporting failure involved a resident who told staff on February 19 that money was missing. The certified nursing assistant who received this complaint asked if the resident wanted to speak with a nurse, but the resident said they were "too upset at the moment" and would report it in the morning. The facility didn't report this potential theft to state authorities until February 23, four days later.
Director of Nursing DON-B discovered the missing money allegation only after reviewing progress notes on February 22. "DON-B came in on the weekend to work on the investigation," inspectors noted.
In a separate incident, a resident complained that Licensed Practical Nurse LPN-Q came into her room "screaming" at her and her visiting son. The resident, who has diabetes and morbid obesity, told inspectors the nurse was angry because she had asked a nursing assistant to delay changing her incontinence product until after her son left.
"LPN-Q came in screaming at us," the resident told inspectors. The resident's son left immediately after the confrontation, and she told investigators: "I wouldn't recommend this place to anyone if I could walk I would be out of here."
The resident reported the incident to a social worker conducting interviews, but the facility didn't report it to state authorities until February 20, after the required timeframe had passed.
Human Resources staff member HR-K, who received the resident's complaint, called Director of Nursing DON-B to report it. But DON-B told HR-K that the resident "is behavioral at times" and decided not to report the incident because the resident said she suffered no "ill effects."
During the inspection, DON-B initially couldn't remember receiving HR-K's call, telling inspectors "I guess" when asked about it and explaining "she gets multiple calls from multiple people."
The facility's abuse prevention policy requires immediate reporting of all allegations to the administrator and state survey agency within two hours for incidents involving abuse or serious injury, and within 24 hours for other incidents. The policy designates an abuse prevention coordinator responsible for reporting and mandates ongoing staff supervision to ensure policy implementation.
The policy specifically lists "verbal abuse of a Resident overheard" as a possible indicator of abuse requiring investigation.
Beyond the reporting failures, inspectors found the facility conducted inadequate investigations. For the dementia resident who was called "dumb" and "bitch," administrators never completed a thorough investigation despite having multiple witnesses. The facility only began investigating the resident's verbal abuse complaint on February 20, days after inspectors arrived.
Administrator NHA-A admitted to inspectors that when initially told about the crying resident on February 11, "NHA-A never thought it was abuse." Even worse, NHA-A and the unit manager brought the accused nursing assistant directly into the victim's room during the preliminary inquiry.
Director of Operations DO-C later had to re-educate NHA-A "not to bring an accused staff member into a Resident's room," according to inspection records.
The investigation failures had serious consequences. Had staff reported the earlier verbal abuse of the dementia resident, inspectors noted, "R2 having been verbally abused by CNA-H would have been prevented."
The facility's problems extended beyond abuse reporting to basic medical care. Inspectors found that residents weren't receiving prescribed treatments on schedule, with some wound care delayed for days.
One resident with surgical wounds told inspectors his treatments were supposed to happen twice daily "but always doesn't get changed." The resident said staff sometimes claimed "the treatment is not showing up in the computer or something like that." When treatments were missed, the resident would ask the next shift to complete them, explaining he didn't want to complain because "don't want them not to do me right."
Another resident with multiple pressure injuries had treatment orders changed by the wound physician on February 12, but the facility didn't implement the new orders until February 20 – eight days later. During one observed treatment, a nurse told the resident her heel treatment had been "discontinued" when it had actually just been modified.
The same resident's specialized air mattress was set to the wrong pressure setting, causing her to complain that she could "feel the bar" in her back. Her pressure-relieving boots went missing, leaving her heels resting directly on the mattress without protection.
A resident at high risk for falls had three unwitnessed falls within three weeks, but the facility never completed root cause analyses or developed targeted interventions. The same resident, who receives all nutrition through a feeding tube due to swallowing problems, was accidentally given a full meal tray in the dining room. Staff told the kitchen the resident was someone else, and the resident "ate the whole tray" of turkey, gravy, stuffing, and cake.
The facility conducted no investigation into how the life-threatening feeding error occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Muskego Health and Rehabilitation Center from 2025-02-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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