Muskego Health And Rehabilitation Center
Muskego Health and Rehabilitation Center in MUSKEGO, WI — inspection on January 27, 2025.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
with a Brief Interview for Mental Status (BIMS) score of 13.
The MDS also documents that the the facility assessed R235 needing extensive assist with 2 staff members for oral/ toileting hygiene, and upper/lower body dressing. R235 was incontinent of bowel and bladder and wore protective briefs.
R235's primary language was Serbian.
Surveyor reviewed a grievance that was reported by R235's family member to Nursing Home Administrator (NHA)-A on 1/9/2025. R235's family member reported that R235 was calling the family member from the night of 1/8/2025 into the morning on 1/9/2025 from 3:00 AM - 5:00 AM stating R235 was wet and needed to be changed. R235's family member stated staff were not answering the facility phone and R235's family member came to the facility. R235's family member also reported that staff was rude and rolling their eyes at R235's family member. R235's family member also reported an incident on 1/3/2025 at 2:00 AM when R235 was calling R235's family member stating R235 was wet and on 1/4/2025 staff was rude and yelled at R235's family member.
On 1/23/2025, at 12:27 PM, Surveyor interviewed NHA-A and asked why the above concerns from R235's family member was not reported when the concerns were brought to NHA-A's attention. NHA-A stated that when NHA-A talked with facility staff they stated that R235's family member was rude to them and telling them how to do cares on R235 and that rounds were being completed every 2 hours.
NHA-A stated that license practical nurse (LPN)-L stated the facility phone never rang.
Surveyor asked how it was verified that the facility phone was working, and that staff were completed rounds as reported. NHA-A stated NHA-A would have to check to see if that was done.
On 1/27/2024, at 10:38 AM, Surveyor shared concern with NHA-A, Director of Nursing (DON)-B, and Director of Operations- E that R235's family members allegation of neglect reported on 1/9/2025 alleging R235 did not have cares completed was not reported to the State Survey Agency.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
and would try to put R7's clothes on. R7 indicated that he told R30 that if R30 keeps touching R7's
occasionally. R7 informed Surveyor R30 was last in R7's room yesterday, R7's new roommate
description of what occurred is different than what the facility documented in the FRI.
On 01/22/2025, at 03:19 PM, Surveyor interviewed LPN-C regarding the FRI. LPN-C indicated she received a call from NHA-A and DON-B that an incident between R7 and R30 had occurred and was asked to come in to the Facility to submit the report due to NHA-A and DON-B being unavailable.
LPN-C indicated LPN-C came into the Facility and spoke with the two nurses on shift, RN-P and LPN-D. LPN-C indicated that R7 was going in while R30 was coming out of the bathroom, R30 was startled, R7 and R30 bumped into each other. LPN-C indicated R7 and R30 were immediately separated and R30's room was changed. R30 was put on 1:1 supervision for 2 days, with no further incidents. LPN-C indicated R7 just does not like people in his space. LPN-C indicated LPN-C interviewed R7 and R30, no other residents were around. LPN-C indicated the next day NHA-A started the investigation, then completed and submitted the report. LPN-C indicated statements were obtained from LPN-D and RN-P, but only has LPN-D's statement documented.
On 01/22/2025, at 03:37 PM, Surveyor interviewed DON-B, in the presence of Director of Operations-E, regarding the FRI. DON-B indicated the incident was reported due to the allegation of resident-to-resident abuse. DON-B indicated that while information came in and the investigation was conducted R7 and R30 were separated, and R30 was put on 1:1 supervision. DON-B indicated that R30 moves about the Facility freely and has attempted to go back to his old room on multiple occasions but is easily redirected. DON-B indicated interviews with R7 and R30 were conducted by NHA-A and LPN-C.
On 01/23/2025, at 03:37 PM, Surveyor informed NHA-A, DON-B, and Director of Operations-E of concerns regarding the investigation, interventions and reporting time of the FRI.
On 01/27/2025, at 08:45 AM, Surveyor interviewed LPN-D regarding the FRI involving R7 and R30.
LPN-D informed Surveyor that R7 came to the nurses' station saying R30 hit R7. LPN-D indicated that they think R7 was trying to hurry to the bathroom and R30 was startled and accidentally hit R7.
LPN-D indicated R30 is not known to hit. LPN-D indicated the residents were separated and R30 was moved to another room. LPN-D indicated no other residents were talked to. LPN-D indicated R30 will occasionally wander into other resident rooms, no previous incidents of hitting and is easily redirected.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
notified of the reason and place of transfer when sent to the hospital. DON-B replied typically with a
No additional information was provided.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
cover with Gauze w/border daily. one time a day for Wound Care -Start Date- 10/05/2024 0700 -D/C
Care -Start Date- 11/16/2024 0700 -D/C Date- 01/13/2025 1250.
Surveyor noted R8's TAR
December 2024 TAR, documents, Mid Lower Back: Cleanse with wound cleanser, apply Xeroform and cover with Gauze w/border three times per week and PRN. one time a day every Mon, Wed, Sat for Wound Care -Start Date- 11/16/2024 0700 -D/C Date- 01/13/2025 1250.
Surveyor noted, R8's TAR documents R8 did not receive wound care to R8's lower back pressure ulcer 6 out of 13 days.
January 2025 TAR, documents Mid Lower Back: Cleanse with wound cleanser, apply Xeroform and cover with Gauze w/border three times per week and PRN. one time a day every Mon, Wed, Sat for Wound Care -Start Date- 11/16/2024 0700 -D/C Date- 01/13/2025 1250 and Mid Lower Back: Cleanse with wound cleanser, apply Calcium alginate and cover with Gauze w/border three times per week and PRN. one time a day every Mon, Wed, Sat for Wound Care -Start Date-01/15/2025 0700.
Surveyor noted, R8 did not receive wound care to R8's lower back pressure ulcer 3 of 10 days.
On 01/23/2025, at 03:37 PM, Surveyor informed NHA-A, DON-B and Director of Operations-E of above concerns regarding R8's wound care treatments not being done consistently and the undocumented skin discolorations.
On 01/27/2025, at 08:39 AM, Surveyor interviewed DON-B regarding concerns with R8 not receiving wound treatments and no documentation of multiple skin discolorations observed to R8's boney prominences. DON-B indicated R8 is receiving palliative care, and they try to address the larger pressure ulcers, that are causing most pain. DON-B indicated the other areas should just be monitored and would expect them to be noted. DON-B indicated being aware of the missing wound treatments on R8's TAR and indicated DON-B did not see anything documented regarding why wound cares were not being done.
No further information provided by Facility as of time of write up.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
Review of R12's TAR revealed 30 instances that staff did not document that R12's splint was placed as ordered. OT changed R12's splint to a palm guard but the physician order and the care plan was not updated. DON-B stated that DON-B would investigate this and get back to Surveyor.
On 1/27/25 at 12:11 PM, DON-B stated that DON-B was able to speak to the therapy department.
DON-B stated that R12 was not tolerating the splint, so OT changed the plan and wanted R12 to wear a palm guard. DON-B indicated that the OT department did not communicate this change to DON-B so that all of nursing staff would know.
No further information was provided as to why the facility did not ensure R12 received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
was within reach. LPN-L stated that LPN-L did not recall.
Surveyor asked who saw R12 last and at
Nurse (RN) to assess the resident. LPN-L would start neuro checks, vital signs and assess range of
bed/chair. LPN-L would notify the doctor, DON and POA (if necessary).
Surveyor asked if there was a fall packet that staff can use to guide them after a residents fall. LPN-L stated, I'm not sure about that.
Surveyor asked if CNA's give statements. LPN-L stated that they usually give verbal statements.
Surveyor asked what happens after the nurse does her part in documenting the fall.
LPN-L stated that management will do the full investigation and the root cause analysis.
Surveyor asked what type of interventions would be put in place if poor lighting was identified as a predisposing factor prior to a fall. LPN-L stated we could put an intervention like nightlight on or keep door open for more light on the resident's care plan.
Surveyor noted that LPN-L stated an unknown CNA informed LPN-L of R12's fall and there is no statement or documentation from the CNA.
Surveyor noted LPN-L was not aware of a fall packet or checklist.
Surveyor noted LPN-L listed fall care plan interventions for poor lighting.
On 1/23/25 at 1:39 PM, Surveyor interviewed Registered Nurse (RN)-O.
Surveyor asked if there was a fall packet or binder to help guide staff after a resident has a fall. RN-O stated yes. RN-O went to a cupboard and pulled out a binder.
Surveyor reviewed the binder and found stapled Fall Check List packets for staff to use to guide them after a fall.
The undated, Falls Check List included the following action items that the floor nurse is responsible for: 1.
Call fall huddle- complete as a team to determine potential root cause and immediate intervention. 2.
Initiate Neuro check if unwitnessed or hit head. 3.
Notify Director of Nursing/Nurse Manager. 4.
Update Care plan/Kardex with immediate intervention. 5.
Notify MD. 6.
Notify 1st Representative. 7.
Complete Risk Management [user defined assessment] in [electronic medical record] . (Note: complete all interviews with staff using the note section.
State who and when you took their statement.) 8.
Complete initial wound assessment, if indicated. 9.
Update 24-hour report.
The Check list included the following action items that the IDT team is responsible for, in part: 1.
Bring found down/fall packet to clinical meeting to review as IDT .
The bottom of the check list documents: Complete fall check list and all items appropriate in Fall/Found Down Packet.
Return to the Director of Nursing.
Survey[TRUNCATED]
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
equipment needed, and cleansing instructions was not placed until 10 weeks after R5's admission.
R5 was receiving the necessary care and treatment for R5's colostomy until after the physician order
On 1/23/25 at 8:46 AM, Surveyor interviewed Registered Nurse (RN)-O.
Surveyor asked how often R5's colostomy bag is changed. RN-O stated that it should be changed every 5 days, but more if needed.
Surveyor asked if there should be a physician order for care of the colostomy. RN-O stated yes.
Surveyor asked where the documentation of colostomy care would be located. RN-O stated it is in the TAR in R5's electronic medical record.
On 1/23/25 at 1:39 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F.
Surveyor asked if there should be a physician order for care of a colostomy. LPN-F stated yes.
Surveyor asked how often care is provided for a colostomy. LPN-F stated that LPN-F would check a colostomy every 2 hours to make sure the bag does not get too full.
Surveyor asked how often the colostomy bag should be changed. LPN-F stated that direction would be in the physician order.
On 1/23/25 at 1:52 PM, Surveyor interviewed Director of Nursing (DON)-B.
Surveyor asked what the expectation for care is on a resident with a colostomy. DON-B indicated that the resident would have a physician order for colostomy care, and it would be in the resident's care plan.
Surveyor asked how often the colostomy bag should be changed. DON-B stated that it should be changed weekly but more often, if needed.
Surveyor informed DON-B of the concern that R5 was admitted with a colostomy but did not have orders for colostomy care until about 10 weeks after admission. DON-B stated that DON-B would get back to Surveyor.
DON-B returned to Surveyor with a copy of R5's progress note dated 11/12/24 at 8:54PM which documented, in part: Colostomy bag changed .
Surveyor noted that the facility provided documentation for colostomy care on 11/12/24. No other documentation for further colostomy care between 10/25/24 and 1/7/25 was provided.
On 1/27/25 at 10:39 AM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that R5 was admitted with a colostomy in October 2024 and did not have a physician order for colostomy care as outlined in the facility policy until January.
No additional information was provided as to why the facility did not ensure R5 received Colostomy care consistent with professional standards of practice.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
completed.
assessment of the resident's condition and monitoring for complications before and after dialysis
On 01/27/25, at 10:50 AM, Surveyor shared the concerns with the Nursing Home Administrator and DON-B regarding only one dialysis communication form being provided for 1/16/25, and 5 other visits (1/14, 1/18, 1/21, 1/23, 1/25) of 2025 were not provided.
Surveyor informed NHA-A and DON-B that R485 had no physician orders put in for dialysis times and days, monitoring before and after and that no care plan specific to R485 was completed for dialysis.
No additional information was provided.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
nurse in charge on each shift.
minimal harm Based on observation, interview, and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial
* The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule.
This deficient practice has the potential to affect all 39 residents residing in the facility.
Findings include: On 1/25/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting low weekend staffing from 12/22/24 through 1/22/25.
Surveyor was provided with the nursing schedules and nurse staff postings and noted the facility's nursing schedules did not designate who the charge nurse was for each tour of duty.
On 1/23/25, at 12:45 PM, Surveyor conducted an interview with Director of Nursing (DON)-B. DON-B stated DON-B is responsible for coordinating the facility's nursing schedule and preparing the facility's nurse staff postings.
Surveyor asked DON-B if they were aware there was not a charge nurse designated on the facility's nursing schedules for Quarter 4 (July 1st -September 30th, 2024) from 12/22/24 through 1/22/25.
DON-B informed Surveyor that the facility will be adding information to the nursing schedules to designate the facility's charge nurse for each tour of duty.
On 1/23/25 at 2:40 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern related to the facility's schedules not designating who the facility charge nurse would be on the facility's nursing schedules for Quarter 4 (July 1st -September 30th, 2024) from 12/22/24-to 1/22/25 for each tour of duty.
The facility did not provide any additional information as to why it did not ensure that the facility designated a charge nurse for each tour of duty.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
(NHA)-A that R29 states RA-T assists R29 into the wheelchair with a pivot transfer and takes R29
the long term care side of the building.
Surveyor also shared there is no indication in the RA job
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
minimal harm staff posting included all required information.
This deficient practice has the potential to affect a pattern of all 39 residents residing in the facility.
The facility nurse staff posting did not include the daily resident census as required.
Findings include: On 1/25/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting low weekend staffing and schedules for 12/22/24 through 1/22/25.
Surveyor reviewed facility's nursing schedules and nurse staff postings.
Surveyor noted the facility did not include the facility's daily census number on the daily nurse staff postings.
On 1/23/25, at 12:45 PM, Surveyor conducted an interview with Director of Nursing (DON)-B. DON-B stated they are responsible for coordinating the facility's nursing schedule and preparing the facility's nurse staff postings.
Surveyor asked DON-B if they were aware the facility did not include the daily census number on the daily nurse staff postings for Quarter 4 (July 1st -September 30th, 2024) and 12/22/24 to 1/22/25. DON-B told Surveyor they will be adding information to the daily nurse staff postings to reflect the daily census for the future nurse staff postings.
On 1/23/25, at 2:40 PM, Surveyor conducted an interview with Nursing Home Administrator (NHA)-A.
Surveyor shared concern that the facility did not include the daily census number on the daily nurse staff postings for Quarter 4 (July 1st -September 30th, 2024) and 12/22/24 to 1/22/25.
The facility did not share any additional information at this time related to above concern.
then make the pharmacy send it.
concern regarding R485 missed 5 doses of Epoetin Alfa Injection Solution 4000 UNIT/ML and the lack
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
was consulted with the recommendation.
were not changed for R21's: lorazepam, zonisamide, or topiramate per recommendation on 9/10/2024.
On 1/27/2025, at 11:31 AM, Surveyor received R21's pharmacy recommendation reviews signed by the physician and new orders written with a physician signature date of 1/27/2025.
Surveyor asked DON-B what the process for the monthly pharmacy reviews was. DON-B replied the pharmacy emails the recommendations to DON-B and the recommendations are then given to the physician, once orders are noted and changed, the physician gives the forms back to DON-B or the floor nurse if DON-B is not available.
Nursing will put in the new order and the signed sheets go to medical records. DON-B was not sure why R21's medication reviews were not reviewed or looked at monthly.
Surveyor shared concern R21's pharmacy medication review recommendations for 9/2024 and 11/2024 were not reviewed by the physician until 1/27/2025 when Surveyor brought it to the facility's attention.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
plan related to anticoagulant and diuretic use and the need to monitor for adverse consequences such as side effects or reactions.
Surveyor asked if there was one to which DON-B responded they did not see anything.
On 01/27/25, at 12:10 PM, Surveyor interviewed DON-B and asked if the Facility policy would indicate needing care plans for anticoagulant or diuretic medications, to which DON-B stated yes both should have been care planned for R31. 2.) R485 was admitted to the facility on [DATE], with diagnoses that include end stage renal disease, chronic obstructive pulmonary disease, systolic (congestive) heart failure, chronic pain syndrome, anxiety disorder, depression, spinal stenosis at cervical region, and mood disorder due to known physiological condition with depressive features.
R485's admission Minimum Data Set (MDS) with an assessment reference date of 1/17/2025 indicated R485 had a Brief Interview for Mental Status score of 15, indicating R15 is cognitively intact. R485 does not have an activated power of attorney. R485 scored a 24 on the patient depression questionnaire indicating severe depression present. R485's MDS documents R485 has an indwelling catheter and is always continent of bowel, and receiving dialysis.
R485 has orders for: -Apixaban Oral Tablet 2.5 MG (milligrams), give 1 tablet by mouth two times a day related to end stage renal disease. -Furosemide Oral Tablet 20 MG, give 1 tablet by mouth one time a day related to essential (primary) hypertension.
Surveyor reviewed R485's electronic medical record and noted there is no person-centered care plan for R485's anticoagulant or diuretic to monitor for adverse side effects of the medications.
On 01/27/25, at 11:28 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R485's care plan related to anticoagulant and diuretic use and the need to monitor for adverse consequences such as side effects or reactions.
Surveyor asked if there was one to which DON-B responded they did not see anything.
On 01/27/25, at 12:10 PM, Surveyor interviewed DON-B and asked if the Facility policy would indicate needing care plans for anticoagulant or diuretic medications, to which DON-B stated that yes both should have been care planned for R485.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
Behavioral Health.
of Nursing (DON)-B regarding not monitor behaviors or side effects of medications and no
On 01/27/25, at 12:10 PM, Surveyor interviewed DON-B and asked should the Facility monitor behaviors and side effects of psychotropic medication and identify non-pharmological interventions when a resident is on a psychotropic and an antidepressant, to which DON-B replied yes, there should be monitoring. 2.) The facility policy entitled Use of psychotropic Medication implemented 10/1/2023 documents: . 9.
PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.
R21 was admitted to the facility on [DATE] and has diagnoses that include dementia, traumatic brain injury, epilepsy (seizure disorder), anxiety, and depression. R21 is enrolled to receive Hospice services and care.
Surveyor reviewed R21's medication orders and noted R21 had an order for: -Lorazepam oral concentrate 2 mg/ml- Give 0.25 ml by mouth every 1 hours as needed for anxiety, restlessness, agitation, seizures.
With a start date of 6/15/2023.
Surveyor noted there was not an end date documented.
On 1/27/2025, at 10:38 AM, Surveyor shared concerns with Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A that R21's lorazepam medication did not have a stop date.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
pressure ulcers that are treated by the Facility along with the wound care team, and has multiple
now have an EBP sign on R8's door.
On 01/23/2025, at 11:57 AM, Surveyor observed LPN-F provide wound care for R8, with Hospice CNA-I assisting.
Surveyor observed LPN-F perform wound care on R8 only wearing gloves.
Surveyor asked LPN-F if R8 is on any precautions. LPN-F indicated R8 is not on any precautions.
Surveyor asked about the sign on R8's door.
Hospice CNA-I went to look at R8's door, and asked when the sign was put there, indicating CNA-I has been here for 2 weeks and no one has said anything and there was only an oxygen sign on the door. LPN-F indicated LPN-F realizes R8 is on EBP for wounds.
LPN-F indicated to Surveyor that LPN-F will ask the Facility where the isolation cart is and ask who the Infection Preventionist is.
On 01/23/2025, at 03:37 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Operations-E of above concerns.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
immunizations.
*R37 consented to the influenza immunization and did not receive it. *R23 consented to the pneumococcal immunization and did not receive it.
Findings include: The facility policy and procedure titled, Infection Prevention and Control Program, dated 5/16/2023 documents: .7.
Influenza and Pneumococcal Immunization: a.
Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. b.
Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c.
Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d.
Residents will have the opportunity to refuse the immunizations. e.
Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations. 1.) R37 gave consent to have the influenza immunization administered but had not received it to date.
In an interview on 1/23/2025, at 9:09 AM, Director of Nursing (DON)-B, also the facility Infection Preventionist, stated R37 needs to have the flu vaccine and DON-B thought they had the vaccine in stock but would have to check.
Surveyor noted an order for the administration of the influenza immunization was not in R37's medical record. 2.) R23 gave consent to have the pneumococcal immunization administered but had not received it to date.
In an interview on 1/23/2025, at 9:09 AM, Director of Nursing (DON)-B, also the facility Infection Preventionist, stated R23 needs to have the pneumonia vaccine and DON-B stated they would have to order it from the pharmacy.
Surveyor noted an order for the administration of the pneumococcal immunization was not in R23's medical record.
On 1/23/2025, at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R37 had not received the influenza vaccine and R23 had not received the pneumococcal vaccine when both had provided consent to receive the vaccines.
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Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
The facility failed to revise the plan of care post R23's fall on 10/29/2024.
* R31 had a fall on 1/5/2025 that was not thoroughly investigated.
* R12 had a fall on 11/24/2024 that was not thoroughly investigated.
* R8 had a fall on 11/3/2024 that was not thoroughly investigated. No interventions were implemented after R8's fall and hospice services were not notified of R8's fall on 11/3/2024.
Findings include:
The facility policy entitled Accidents and Supervision implemented on 12/29/2029 documents: Policy: The resident environment will remain as free of accident hazards as is possible.
Each resident will receive adequate supervision and assistive devices to prevent accidents.
This includes:
1.
Identifying hazard(s) and risk(s).
2.
Evaluating and analyzing hazard(s) and risk(s)
3.
Implementing interventions to reduce hazard(s) and risk(s)
4.
Monitoring for effectiveness and modifying interventions when necessary.
Policy Explanation and Compliance Guidelines: .
2.
Evaluation and Analysis- the process of examining data to identify specific hazards and risks to develop targeted interventions to reduce the potential for accidents.
Interdisciplinary involvement is a critical component of this process.
525686
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525686 B.
Wing 01/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Muskego Health and Rehabilitation Center S77 W18690 Janesville Rd Muskego, WI 53150
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.