Muskego Health Care Center
Inspection Findings
F-Tag F609
F-F609).
Surveyor reviewed a 30 day look back for Resident R235's task documentation. Surveyor noted Resident R235 did not have any documentation indicating incontinence cares had been done every two hours on 1/8/2025 and 1/9/2025 under the bowel and bladder incontinence task, or the toileting task.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 On 1/23/2025, at 7:36 AM, Surveyor interviewed CNA-M who stated CNA-M met Resident R235's family member in
the hallway and asked if they needed anything. CNA-M stated Resident R235's family member walked right past and Level of Harm - Minimal harm or stated Resident R235's family had been calling but CNA-M could not recall the phone ringing. CNA-M walked with potential for actual harm Resident R235's family member to the room and Resident R235's family member stated Resident R235 needed to be changed and new gown put on. CNA-M stated that Resident R235 was not assigned to her, but CNA-M grabbed the necessary supplies Residents Affected - Few and started to assist Resident R235. CNA-M stated that Resident R235's CNA that was assigned came in to help and Resident R235's family member was trying to tell them how to do cares on Resident R235 because it was how Resident R235's family member wanted it done. Surveyor asked if tasks get documented anywhere indicating it was done. CNA-M stated that when tasks are completed, they get documented in PCC (Point Click Care- Healthcare software). CNA-M stated that Resident R235 was not assigned to her so CNA-M would not have charted on Resident R235.
Surveyor notes that the CNA on Resident R235's assignment 1/8/2025 - 1/9/2025 was no longer employed at the facility and was not available for interview.
On 1/23/2025, at 12:27 PM, Surveyor interviewed NHA-A who stated staff and nursing reported rounds were being done on residents. Surveyor asked how that was verified. NHA-A stated NHA-A would have to look and see. Surveyor asked if the phone was looked at or verified that it had no missing calls. NHA-A stated LPN-L stated there were no calls made to the phone that night but did not look. NHA-A stated that CNA-M was already in the room when Resident R235's family member came to the facility. Surveyor stated that CNA-M stated to Surveyor that CNA-M had met Resident R235's family member in the hallway and walked to Resident R235's room with them and then completed incontinence cares.
On 1/27/2025, at 9:00 AM Surveyor interviewed LPN-L who stated Resident R235's family member came the facility and stated Resident R235 needed to be changed and CNA-M assisted with the cares. LPN-L stated LPN-L did not get
a call that night on the phone and showed Resident R235's family member that the phone had no missed calls.
On 1/27/2025, at 10:38 AM, Surveyor shared concern with NHA-A and DON-B that Resident R235's family member concern that Resident R235 was not changed the night of 1/8/2025 into 1/9/2025 was not thoroughly investigated. Surveyor asked how it was verified that Resident R235 was being rounded on and check and changed every two hours. DON- B stated that CNAs are to document when tasks are completed, that includes repositioning, incontinence cares, hygiene, etc. Surveyor requested to see the documented tasks completed for Resident R235.
Surveyor was provided a 3 day bowel and bladder tracker for Resident R235. Surveyor noted staff documented two times at 6:00 AM and 7:00 AM on 1/5/2025. DON-B stated there was no other documentation regarding tasks being completed for Resident R235 for incontinence cares or hygiene cares that DON-B could find.
49845
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 2.) On 12/16/2024 the facility submitted a facility reported incident (FRI) regarding a resident to resident altercation between Resident R7 and Resident R30. The FRI documents that an incident occurred on 12/14/2024 involving Resident R7 Level of Harm - Minimal harm or and Resident R30. The report documents, Resident R30 was in the restroom in Resident R30's room. Resident R30's roommate, Resident R7, entered the potential for actual harm room to use the restroom. Upon Resident R7 entering the room Resident R30 was exiting at the same time and Resident R30's hand connected with Resident R7's shoulder. Resident R7 then reported to RN that Resident R30's hand connected with Resident R7's shoulder. Residents Affected - Few Surveyor noted there are documented statements from Nursing Home Administrator (NHA)-A, Licensed Practical Nurse (LPN)-D, and LPN-C. Surveyor noted Interviews documented with Resident R7 and Resident R30, documented by NHA-A. Surveyor noted there were no other interviews with facility staff or residents as part of the investigation.
On 01/22/2025, at 10:06 AM, Surveyor interviewed Resident R7 regarding the incident. Surveyor noted Resident R7 has bilateral lower extremity amputations, and independently moves around in wheelchair. Resident R7 indicated Resident R30 use to be Resident R7's roommate. Resident R30 indicated to Surveyor that on the day of the incident, Resident R7 went back to Resident R7's room
after leaving the shower room. Resident R7 indicated Resident R30 was in Resident R7's bed. Resident R30 got out of Resident R7's bed and hit Resident R7 in the left shoulder with a fist but denies injuries. Resident R7 indicated Resident R7 then went and told the nurse and had Resident R30 removed from his room. Resident R7 indicated Resident R30 would always go through Resident R7's things and would try to put Resident R7's clothes on. Resident R7 indicated that he told Resident R30 that if Resident R30 keeps touching Resident R7's clothes, Resident R7 would cut Resident R30's hands off. Resident R7 indicated that Resident R30 eats off his and other residents' trays. Resident R7 informed Surveyor that Resident R30 has been moved to another room, but still comes into Resident R7's room occasionally. Resident R7 informed Surveyor Resident R30 was last in Resident R7's room yesterday, Resident R7's new roommate confirmed this as well. Resident R7 denies any further altercations occurring Resident R30. Surveyor noted Resident R7's 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 Resident R7 and Resident 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 Resident R7 was going in while Resident R30 was coming out of the bathroom, Resident R30 was startled, Resident R7 and Resident R30 bumped into each other. LPN-C indicated Resident R7 and Resident R30 were immediately separated and Resident R30's room was changed. Resident R30 was put
on 1:1 supervision for 2 days, with no further incidents. LPN-C indicated Resident R7 just does not like people in his space. LPN-C indicated LPN-C interviewed Resident R7 and Resident 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 Resident R7 and Resident R30 were separated, and Resident R30 was put on 1:1 supervision. DON-B indicated that Resident 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 Resident R7 and Resident 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 On 01/27/2025, at 08:45 AM, Surveyor interviewed LPN-D regarding the FRI involving Resident R7 and Resident R30. LPN-D informed Surveyor that Resident R7 came to the nurses' station saying Resident R30 hit Resident R7. LPN-D indicated that they think Resident R7 Level of Harm - Minimal harm or was trying to hurry to the bathroom and Resident R30 was startled and accidentally hit Resident R7. LPN-D indicated Resident R30 is not potential for actual harm known to hit. LPN-D indicated the residents were separated and Resident R30 was moved to another room. LPN-D indicated no other residents were talked to. LPN-D indicated Resident R30 will occasionally wander into other resident Residents Affected - Few rooms, no previous incidents of hitting and is easily redirected.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49845 potential for actual harm Based on observation, interview, and record review, the facility did not ensure residents with pressure Residents Affected - Few injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (Resident R8) of 2 residents reviewed with pressure injuries.
* Resident R8 did not receive treatment of Resident R8's lower back pressure injury 20 days out of 71 days. Resident R8 did not have documentation of multiple skin discolorations over boney prominence areas where pressure injuries are likely to occur.
Findings include:
Resident R8 was admitted to the facility on [DATE REDACTED] with diagnoses which include malnutrition, osteoporosis, peripheral vascular disease, vascular dementia, and major depressive disorder. Resident R8 has a Legal Guardian.
Resident R8's Annual Minimum Data Set (MDS), dated [DATE REDACTED], documents Resident R8 has a Brief Interview for Mental Status (BIMS) score of 01, did not exhibit behaviors, had impairment in upper and lower extremities, partial/moderate assistance with rolling left to right, and at risk for pressure injuries.
Resident R8's most recent MDS is a Significant Change, dated 10/28/2024, and documents a BIMS of 01, no behaviors, on a scheduled pain medication regimen, prognosis of life expectancy less than 6 months, at risk for pressure injuries, has one or more unhealed pressure injuries, 1 slough and/or eschar pressure injury, 1 unstageable deep tissue injury, skin tears, receiving pressure injury care, surgical wound care, and is now on hospice.
Surveyor reviewed the Facility's document titled, Resident Matrix, and noted Resident R8 is documented to have a pressure injury that was not present on admission.
On 01/22/2025, at 09:47 AM, Surveyor noted no Enhanced Barrier Precautions (EBP) sign on Resident R8's door. Surveyor spoke with Hospice RN-K. Hospice RN-K indicated Resident R8 has daily hospice visits, has 2 pressure ulcers that are treated by the Facility and wound care, and multiple other not opened pressure ulcers and indicated there are too many to count. Hospice RN-K indicated Resident R8 is on scheduled end of life medications.
On 01/23/2025, at 10:18 AM, Surveyor noted Resident R8 to now have an EBP sign on Resident R8's door while waiting for nurse to preform wound care for Resident R8.
On 01/23/2025, at 11:57 AM, Surveyor observed LPN-F provide wound care for Resident R8, with Hospice CNA-I assisting. LPN-F indicated Resident R8 has 2 open pressure uclers and one healed on the left heel. Surveyor observed LPN-F preform wound care on Resident R8 only wearing gloves. Surveyor observed 2 open pressure injuries, 1 to Resident R8's left lower back and 1 to Resident R8's left hip. Surveyor asked to see Resident R8's heel, Surveyor observed multiple small, purple discolorations to Resident R8's bilateral heels/feet.
Surveyor reviewed Resident R8's wound documentation from Vohra. Surveyor noted the following measurements:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686 10/9/2024- UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS,
Level of Harm - Minimal harm or wound Size: 1 x 3 x 0.1 cm potential for actual harm 10/16/2024 Residents Affected - Few UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 2 x 1 x 0.1 cm
10/23/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 2 x 1 x 0.1 cm
10/30/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 2 x 1 x 0.1 cm
11/6/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 1 x 1 x 0.1 cm
11/20/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 0.8 x 1 x 0.1 cm
11/27/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 0.8 x 0.8 x 0.1 cm
12/04/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 0.8 x 0.8 x 0.1 cm
12/11/2024
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686 UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Level of Harm - Minimal harm or Wound Size: 0.8 x 0.8 x 0.1 cm potential for actual harm 12/18/2024 Residents Affected - Few UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 0.8 x 0.8 x 0.1 cm
12/25/2024
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 1 x 1.5 x 0.1 cm
01/01/2025
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 2 x 2 x 0.5 cm
01/08/2025
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 2 x 2 x 0.5 cm
01/15/2025
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 6 x 4 x 0.5 cm
01/22/2025
UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT LOWER BACK FULL THICKNESS
Wound Size: 6 x 4 x 0.5 cm
Surveyor noted an increase in Resident R8's lower back pressure ulcer, over the course of 14 weeks, from 1 x 3 x 0.1 cm to 6 x 4 x 0.5 cm.
Surveyor reviewed Resident R8's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2024 through January 2025. Surveyor noted the following:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686 October 2024 TAR documents, Mid Lower Back: Cleanse with wound cleanser, apply Xeroform and cover with Gauze w/border daily. one time a day for Wound Care -Start Date- 10/05/2024 0700 -D/C Date- Level of Harm - Minimal harm or 11/14/2024 1237. Surveyor noted Resident R8's TAR indicates Resident R8's did not receive treatment of Resident R8's lower back potential for actual harm pressure injury 8 out of 27 days.
Residents Affected - Few November 2024 TAR documents, Mid Lower Back: Cleanse with wound cleanser, apply Xeroform and cover with Gauze w/border daily. one time a day for Wound Care -Start Date- 10/05/2024 0700 -D/C Date- 11/14/2024 1237 and 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 Resident R8's TAR documents Resident R8 did not receive wound care to Resident R8's lower back pressure ulcer 3 of 21 days.
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, Resident R8's TAR documents Resident R8 did not receive wound care to Resident 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, Resident R8 did not receive wound care to Resident 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 Resident 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 Resident R8 not receiving wound treatments and no documentation of multiple skin discolorations observed to Resident R8's boney prominences. DON-B indicated Resident 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 Resident 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49435
Residents Affected - Few Based on observations, interview and record review, the facility did not ensure that 1 (Resident R12) of 1 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
* Resident R12 has a physician order for a splint to be worn on the right hand. Surveyor observed Resident R12 wearing a palm guard on Resident R12's right hand on the first day of survey. Surveyor had multiple observations of Resident R12 not wearing
a splint or a palm guard on Resident R12's right hand during the remainder 2 days of the survey.
Findings include:
1.) Resident R12 was admitted to the facility on [DATE REDACTED] with diagnosis that include Hemiplegia (muscle weakness or partial paralysis on one side of the body) following stroke affecting right dominant side, Aphasia (language disorder that affects ability to understand and express language), and Vascular Dementia.
Resident R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], documents Resident R12's cognition is moderately impaired. Resident R12 uses a wheelchair. Resident R12 mobility requires partial to moderate assistance. Resident R12 requires substantial/maximal assistance for transfers. Resident R12 has a functional limitation in range of motion (ROM) affecting the upper and lower extremities on one side of the body.
On 1/22/25 at 12:48 PM, Surveyor observed Resident R12. Resident R12 was unable to answer Surveyors questions due to Resident R12's Aphasia. Surveyor noted Resident R12 had a contracture to Resident R12's Right hand. Resident R12 was wearing a white palm guard on Resident R12's right hand.
Resident R12's physician order with a start date of 7/27/24 documents, Splint: Type- Resting hand splint. Location - Right hand. Wear Schedule- [Put on] in the am for 6 hours. Needs que for timing to [take off]. in the morning related to hemiplegia and hemiparesis following [stroke].
Resident R12's Contracture Management Care plan initiated on 6/12/23 documented: Impaired mobility [related to] impaired ROM. [Resident R12] has contractures to [right upper extremity] and [right lower extremity] due to [stroke]. Interventions included, in part: Assess [Resident R12] on admission, quarterly, and [as needed] for limitations in [Resident R12's] ROM. Assess [Resident R12] for [complaints of] stiffness or limitation with his ROM. Monitor [Resident R12] for [complaints of] pain to affected limb . Implement measures to minimize and/or prevent contractures in [Resident R12's] upper extremities. Encourage [Resident R12] to use upper extremities to perform self-care and assist in moving unless contraindicated. Provide for therapy consult if indication of [Resident R12's] ROM becomes restricted or demonstrates further evidence of decline [as needed].
Surveyor noted that a splint or palm guard was not listed as an intervention on Resident R12's care plan.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Surveyor reviewed Resident R12's Treatment Administration Record (TAR) from 8/1/24 through 1/27/25. Surveyor noted staff did not always document that Resident R12's splint was being worn. Surveyor noted missing Level of Harm - Minimal harm or documentation for the following dates: 8/1/24, 8/2/24, 8/8/24, 9/2/24, 9/9/24, 10/3/24, 10/11/24, 10/23/24, potential for actual harm 10/24/24, 10/25/24, 10/28/24, 10/29/24, 10/30/24, 10/31/24, 11/13/24, 11/27/24, 12/3/24, 12/4/24, 12/11/24, 12/14/24, 12/15/24, 12/19/24, 12/24/24, 1/2/25, 1/9/25, 1/16/25, 1/17/25, 1/21/25, 1/22/25 and 1/27/25. Residents Affected - Few Surveyor noted a total of 30 occurrences that staff did not document that Resident R12's splint was put on in the morning and off after 6 hours.
Surveyor reviewed Resident R12's Occupation Therapy (OT) Treatment encounter notes. On 1/2/25, OT note documents, in part: . OT performed goniometer measurements for contracture management and splint selection.
On 1/9/25, OT note documents, in part: . Discussed treatment plan with wearing splint. [Resident R12] continues to be hesitant as if [Resident R12] does not want to wear it. OT did not [put on] splint.
On 1/15/25, OT note documents, in part: . completed thorough hand hygiene to right hand and noted areas that appeared macerated with white patches, flaking of skin where thumb was rubbing on palm and 2nd and 3rd digit. Following hand hygiene and stretching, at end of session skin looked significantly better but continued to have areas of excoriation. Placed resting hand splint on but [Resident R12] did not appear comfortable with wearing. [Resident R12] agreeable to trial of palm guard. [Put on] palm guard to test tolerance, monitored [every 1 hour] with good tolerance. Noted decreased tone in hand with wearing and improved skin integrity of palm .
On 1/16/25, OT note documents, in part: . OT [put on] [Resident R12's] palm guard and [Resident R12] reports liking it. Discussed using this verses the splint and [Resident R12] wants the palm guard. [Resident R12] tolerated wearing it for 5 hours without issues.
On 1/21/25, OT note documents, in part: . OT [put on] [Resident R12's] palm guard . [Resident R12] could tolerate wearing it for 6 hours.
On 1/23/25, OT note documents, in part: . OT [put on] [Resident R12's] palm guard. [Resident R12] appears to like it and can tolerate it for 6 hours .
Surveyor noted OT had changed Resident R12's contracture management plan from a splint to a palm guard and Resident R12's physician orders and Resident R12's care plan was not updated.
On 1/23/25 at 8:48 AM, Surveyor observed Resident R12 in Resident R12's wheelchair. Resident R12 is not wearing a splint or palm guard on Resident R12's right hand.
On 1/23/25 at 9:38 AM, 10:44 AM, 12:52 PM and 1:30 PM, Surveyor observed Resident R12 in Resident R12's wheelchair. Resident R12 was observed not wearing a splint or palm guard on Resident R12's right hand.
On 1/27/25 at 8:04 AM and at 10:10 AM, Surveyor observed Resident R12 in Resident R12's wheelchair. Resident R12 was observed not wearing a splint or palm guard on Resident R12's right hand.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 On 1/23/25 at 1:35 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-R about Resident R12. CNA-R stated that Resident R12 is very cooperative and pleasant. CNA-R stated that Resident R12 will wear Resident R12's splint when Resident R12 is Level of Harm - Minimal harm or supposed to. potential for actual harm
On 1/23/25 at 1:58 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-N about Resident R12. CNA-N stated Residents Affected - Few that Resident R12 is cooperative and wears Resident R12's splint on Resident R12's right hand daily.
On 1/27/25 at 10:13 AM, Surveyor interviewed OT assistant (OTA)-U. Surveyor asked how Resident R12 is with wearing a splint/palm guard. OTA-U stated that Resident R12 is cooperative but remembers seeing Resident R12 a couple weeks ago and noted that Resident R12's right hand was really tight, and OTA-U noted some maceration areas. OTA-U stated that Resident R12 was then changed from a resting hand splint to a palm guard and Resident R12 seemed to tolerate that. OTA-U stated that OTA-U does not work full time at the facility and would have to look back at
the OT's notes to see if the palm guard was continued. Surveyor asked OTA-U to bring any further information to Surveyor. OTA-U did not return to Surveyor.
On 1/27/25 at 10:39 AM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concerns that Resident R12 has an order for a splint to be worn on the right hand. Surveyor observed Resident R12 wearing a palm guard on Resident R12's right hand on the first day of survey. Surveyor had multiple observations of Resident R12 not wearing a splint or a palm guard on Resident R12's right hand during the remainder of the survey. Review of Resident R12's TAR revealed 30 instances that staff did not document that Resident R12's splint was placed as ordered. OT changed Resident 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 Resident R12 was not tolerating the splint, so OT changed the plan and wanted Resident 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 Resident R12 received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47094
Residents Affected - Some Based on interview and record review, the facility did not ensure that residents remain as free of accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents for 5 (Resident R8, Resident R12, Resident R23, Resident R29, and Resident R31) of 6 residents reviewed for falls and 1 (Resident R29) of 2 residents reviewed for smoking.
* Resident R29 had a fall on 8/31/2024 that was not thoroughly investigated and Resident R29's care plan was not revised until 9/3/2024.
* Resident R29 had a smoking evaluation completed on 8/13/2024. The smoking evaluation indicated that the facility holds onto Resident R29's smoking supplies and should be a supervised smoker. Resident R29 did not have a smoking care plan and had smoking supplies located in Resident R29's purse in her room. Resident R29 did not have any additional smoking evaluation assessments completed.
* Resident R23 had a fall on 10/29/2024 that was not thoroughly investigated. The facility failed to revise the plan of care post Resident R23's fall on 10/29/2024.
* Resident R31 had a fall on 1/5/2025 that was not thoroughly investigated.
* Resident R12 had a fall on 11/24/2024 that was not thoroughly investigated.
* Resident R8 had a fall on 11/3/2024 that was not thoroughly investigated. No interventions were implemented after Resident R8's fall and hospice services were not notified of Resident 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. Level of Harm - Minimal harm or potential for actual harm b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, Residents Affected - Some and identifying or developing interventions based on the severity of the hazards and immediacy of risk.
c. Evaluations also look at trends such as time of day, location, etc.
3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes:
a. Communicating the interventions to all relevant staff.
b. Assigning responsibility.
c. Providing training as necessary.
d. Documenting interventions.
e. Ensuring interventions are put into action.
f. Interventions are based on the results of the evaluation and analysis of information about -hazards and risks and are consistent with relevant standards, including evidenced-based practice.
g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully.
h. Facility-based interventions may include, but are not limited to- educating staff .
i. Resident-directed approaches may include- implementing specific interventions as part of the plan of care .
4. Monitoring and Modification- Monitoring the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective
in addressing hazards and risks. Monitoring and modification processes include:
a. Ensuring that interventions are implemented correctly and consistently.
b. Evaluating the effectiveness of interventions.
c. Modifying or replacing interventions as needed.
d. Evaluating the effectiveness of new interventions.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 The policy entitled Resident Smoking revised on 12/15/2023 documents: Policy: It is the policy facility to provide a safe and healthy environment for residents, visitors, and employees, including safety related to Level of Harm - Minimal harm or smoking. Safety protections apply to smoking and non-smoking residents. potential for actual harm Policy Explanations and Compliance Guidelines: . Residents Affected - Some 5. Residents will be asked about tobacco use during the admission process, reviewed quarterly and as needed.
6. Resident who smoke will be further evaluated using the Smoking Evaluation to determine supervision need and intervention.
8. Any resident who is deemed safe to smoke with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times and in accordance wit the individualized care plan.
10. All safe smoking measures will be documented on the care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on the care plan.
13. Smoking materials of residents requiring supervision with smoking will be maintained by facility staff.
a. Storage of cigarettes and lighters: Wall mounted lock box on [name of unit] at the nurse's station.
14. The interdisciplinary team (IDT), with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by: .
d. Developing a safe smoking plan, or an individualized plan to quit smoking safely.
1.) Resident R29 was admitted to the facility on [DATE REDACTED] and has diagnoses that includes multiple sclerosis, generalized anxiety disorder, and recurrent depressive disorder.
Resident R29's quarterly minimum data set (MDS) dated [DATE REDACTED] indicated Resident R29 had intact cognition with a Brief
Interview for Mental Status (BIMS) score of 15 and the facility assessed Resident R29 being dependent on 1 staff member for personal and toileting hygiene, lower body dressing, and putting on/ off footwear, and Resident R29 had impairments to both right and left side upper and lower extremities. Resident R29 required a sit to stand device for transferring and required max assist with 1 staff member for repositioning in bed. The facility assessed Resident R29
on 7/16/2024 to be a moderate risk for falls with a fall risk assessment score of 11.
Resident R29's risk for falls, accidents and incidents related to medication use, poor functional mobility care plan initiated on 7/17/2024 with the following interventions:
- Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 - Follow facility fall protocol.
Level of Harm - Minimal harm or - Anticipate and meet the residents needs. (initiated 7/22/2024) potential for actual harm - Educate resident/ family/ caregivers about safety reminders and what to do if a fall occurs. Residents Affected - Some - Ensure that the resident is wearing appropriate footwear.
- Pt evaluate and treat as ordered or PRN (as needed).
On 8/31/2024, at 19:38 (7:38 PM) in the progress notes nursing documented Resident R29 was found on the floor by certified nursing assistant (CNA). Resident R29's vital signs taken . Resident R29 stated complains of pain in Resident R29's legs. Resident R29 stated hit Resident R29's head but denied pain, no signs of shortness of breath of chest pain. Resident R29 refuses to be sent to the emergency room and is Resident R29 own person.
On 9/3/2024, at 9:04 AM, in the progress notes IDT documented review of Resident R29's fall on 8/31/2024. Resident R29 had
an unwitnessed fall in room. Resident R29 was found on the floor next to Resident R29's bed. Resident R29 stated she just fell . Resident R29 stated hitting Resident R29 but wished not to be sent out. Neurological checks completed and assessment indicated no injuries. Resident R29 was assisted off the floor with a Hoyer lift. Physician, director of nursing (DON), and Resident R29's family were updated. Root cause analysis revealed that Resident R29 was trying attempting to self-transfer. Interventions include encouraging Resident R29 to call for assistance prior to transferring.
On 1/23/2025, at 9:00 AM, Surveyor observed Resident R29 lying in bed watching TV. Resident R29 stated Resident R29 had a couple falls but could not remember any details as to when or why. Resident R29 stated Resident R29 usually calls if needs assistance with anything in between staff checking on Resident R29.
Surveyor reviewed Resident R29's Falls care plan and notes Resident R29's care plan was not revised until 9/3/2024 with the following intervention:
- Encourage resident to call for assistance with all transfers.
- Encourage resident to call for assistance when needed objects are out of reach. (initiated 9/16/2024).
Surveyor reviewed the fall investigation for Resident R29's fall on 8/31/2024. Surveyor notes that resident statement documented Resident R29 saying Resident R29 just fell . There were no staff interviews included to determine when Resident R29 was last checked on or toileted, or what the environment was like when Resident R29 was found on the floor. Surveyor noted no indication what interventions were in place or what interventions were implemented after the fall.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 1/27/25, at 8:59 AM, A Surveyor interviewed licensed practical nurse (LPN)-L, Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get an RN to assess Level of Harm - Minimal harm or the resident. LPN-L would start neurological checks, vital signs and assess range of motion. If everything potential for actual harm was okay, LPN-L would get help to move the resident with the Hoyer lift back into bed/chair. LPN-L would notify the MD (medical doctor), DON and POA (if necessary). Surveyor asked if there was a fall packet that Residents Affected - Some staff can use to guide them after a residents fall. LPN- 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.
On 1/27/2025, at 10:38 AM Surveyor shared concerns nursing home administrator (NHA)-A and DON-B that
the investigation for Resident R29's fall on 8/31/2024 was not thoroughly investigated and did not include interviews indicating when Resident R29 was last checked and changed, what interventions were in place at time Resident R29 was found
on the floor, or what interventions were implemented right away to prevent another fall.
2.) Resident R29's admission MDS dated [DATE REDACTED] documents under section J on the MDS under current tobacco use,
the answer no was checked indicating Resident R29 did not currently use tobacco.
Resident R29's quarterly MDS dates 12/19/2024 documents under section J on the MDS under tobacco use, there was no documentation marked under current tobacco use.
On 8/13/2024 a smoking evaluation assessment was completed and documented Resident R29 smokes cigarettes 1-2 times a day, cannot light own cigarettes, the facility was to store Resident R29's lighter and cigarettes, and that Resident R29 was not safe to smoke independently and was a supervised smoker.
On 1/23/2025, at 9:00 AM, Surveyor observed Resident R29 lying in bed watching TV. Resident R29 stated Resident R29 goes outside once in a while to smoke. Resident R29 stated Resident R29 used to go out 1 time a day depending on the weather and what staff was working. Surveyor asked Resident R29 if Resident R29 had own smoking supplies. Resident R29 stated that Resident R29's smoking supplies are in her purse. Surveyor asked if Resident R29 smokes alone or if staff stay with Resident R29. Resident R29 stated staff stay with Resident R29 when she smokes.
On 1/23/2025, at 9:44 AM, Surveyor reviewed the facility list with resident's that smoke. Resident R29 was not listed
on the smoking list.
Surveyor reviewed Resident R29's care plan and noted there was not a care plan for smoking.
Surveyor reviewed Resident R29's CNA care card and noted there was no interventions or indications that Resident R29 smoked.
On 1/23/2025, at 10:31 AM, Surveyor interviewed registered nurse (RN)-O who stated Resident R29 does not go out very often to smoke, not even once a week. Surveyor asked if Resident R29 had to be supervised and where Resident R29's smoking supplies are kept. RN-O stated staff need to stay with Resident R29 while smoking and that Resident R29 had her own smoking supplies.
On 1/23/2025, at 2:01 PM, Surveyor interviewed CNA-N who stated Resident R29 needs someone to stay with her while smoking and that Resident R29 has her own smoking supplies. CNA-N stated that Resident R29 does not go out a lot to smoke, somedays she will and then there will be several days she does not.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 1/27/2025, at 8:42 AM, Surveyor interviewed CNA-S who stated Resident R29 does not go out often to smoke, maybe once a week if that. CNA-S stated Resident R29 has her own smoking supplies and staff are to stay with Resident R29 Level of Harm - Minimal harm or while smoking. potential for actual harm
On 1/27/2025, at 10:38 AM, Surveyor shared concerns with NHA-A and DON-B that Resident R29 did not have a Residents Affected - Some smoking care plan, no other smoking assessments had been completed since 8/2025, and that Resident R29 has smoking supplies which the smoking assessment completed 8/2024 indicated the facility should hold onto her smoking supplies.
No additonal information was provided.
49011
3.) Resident R23 was admitted to the facility on [DATE REDACTED] from the hospital with diagnoses that includes paraplegia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic pain syndrome, neuromuscular dysfunction of bladder, neurogenic bowel, and major depressive disorder.
Resident R23's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/15/2025 indicated Resident R23 had a Brief Interview for Mental Status score of 02 (severe cognitive impairment). Resident R23 has an activated Power of Attorney (POA). Resident R23's MDS was coded that for toileting Resident R23 has an indwelling catheter and an ostomy bag. The MDS noted no falls since admission or reentry.
Surveyor reviewed Resident R23's care plan and noted the following: The resident is at risk for falls, accidents and incidents r/t (related to) antidepressant use, NWB (non-weight bearing) d/t (due to) paraplegia. Revision on: 08/27/2024.
The goal set is the resident will be free of falls through the review date. Revision on: 01/15/2025, with a target date of 04/15/2025.
Interventions are:
- Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
Date Initiated: 08/15/2024
- Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.
Date Initiated: 08/27/2024
- Follow facility fall protocol.
Date Initiated: 08/15/2024
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 01/22/25, at 11:16 AM, Surveyor reviewed a progress note written on 10/29/2024, at 07:45 AM, which documents: Vss (vital signs stable). Resident had no issues most of the night. Resident bed was lowered to Level of Harm - Minimal harm or the floor resident fell out of the bed he denied any complaints of pain or discomfort he denied hitting his potential for actual harm head. Resident was assessed got him back up and put in bed Resident was also educated on his safety and
the falling out of the bed falling. DON (Director of Nursing) notified, will continue to monitor. Residents Affected - Some Surveyor requested the fall investigation information from the Facility and reviewed it. Under the category of Statements it reads no statements found. No post fall statements were obtained from staff or the resident about the resident or their condition post fall. There was no information documented as to when the resident was last seen. There is a statement IDT (Interdisciplinary Team) Fall: Resident had an unwitnessed fall from bed. He was found lying next to his bed. He stated that he rolled from bed. He denies hitting his head. Assessment WNL (within normal limits). VSS. No complaints of pain. Neuro check completed and negative. Resident was assisted from the floor back into bed. Resident was last rounded on around 6am. He has a catheter and ostomy. Resident had call light within reach. Root cause analysis revealed that resident rolled from bed. Intervention include education about using call light when needing repositioning help.
Surveyor noted the invention was not added to the care plan. Surveyor notes the information of resident was last rounded on at 6am is included, but no statements are included to know where this time came from.
On 01/23/25, at 09:50 AM, Surveyor interviewed Registered Nurse (RN)-O regarding when a resident has a fall, what are the next steps. RN-O stated with an unwitnessed fall, the nurse would assess to make sure the resident is okay, then with help get them up. The nurse then should contact the doctor, family, and case manager if resident has one. Surveyor asked how the fall is investigated and RN-O stated that the Director of Nursing (DON)-B does post investigation and they look at risk management. Surveyor asked about interviews or statements after the fall and RN-O stated that there are no interviews unless there are questions about cause of the fall.
On 01/23/25, at 01:40 PM, Surveyor interviewed (DON)-B and asked about witness statements. DON-B stated they get statements if there are witnesses. For unwitnessed falls the DON speaks with Certified Nursing Assistants (CNA) to determine when they last rounded and if there is any other information.
On 1/27/25 at 8:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L. Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get an RN to assess the resident. LPN-L would start neuro checks, vital signs and assess range of motion. If everything was ok, LPN-L would get help to move the resident with the Hoyer lift back into 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 01/27/25, at 10:52 AM, Surveyor informed the Nursing Home Administrator and the DON-B of the concerns of no care plan intervention added after the fall. The intervention was determined as to use call Level of Harm - Minimal harm or light when needing repositioning help but was not implemented. The lack of thorough investigation to include potential for actual harm post fall statements and when the resident was last rounded on.
Residents Affected - Some No additional information was provided.
4.) Resident R31 was admitted to the facility on [DATE REDACTED] from the hospital with diagnoses that includs chronic migraine without aura, morbid (severe) obesity, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, major depressive disorder, and type 2 diabetes mellitus.
Resident R31's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/15/2024 indicated Resident R31 had a Brief Interview for Mental Status score of 14 (cognitively intact). Resident R31 is responsible for self. Resident R31's MDS was coded that for toileting Resident R31 is frequently incontinent of bladder and always continent of bowel. The MDS noted no falls since admission or reentry.
Surveyor reviewed Resident R31's care plan and noted the following: The resident is at risk for falls, accidents and incidents r/t (related to) impaired mobility secondary to recent spinal surgery with complications, morbid obesity, asthma, acute respiratory failure with hypoxia. Revision on: 08/19/2024.
The goal set is the resident will be free of falls through the review date. Revision on: 08/26/2024, Target Date: 02/09/2025.
Interventions are:
- 1/6: Reeducation on using call light for all transfers.
Date Initiated: 01/06/2025
- Anticipate and meet the resident's needs.
Date Initiated: 08/19/2024
- Be sure the resident's call light is within reach and encourage the resident to use it
for assistance as needed. The resident needs prompt response to all requests for
assistance.
Date Initiated: 08/10/2024
- Educate the resident/family/caregivers about safety reminders and what to do if a
fall occurs.
Date Initiated: 08/19/2024
- Ensure that The resident is wearing appropriate footwear when ambulating or
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 mobilizing in w/c (wheel chair).
Level of Harm - Minimal harm or Revision on: 08/19/2024 potential for actual harm - Follow facility fall protocol. Residents Affected - Some Date Initiated: 08/10/2024
- Pt (physical therapy) evaluate and treat as ordered or PRN.
Date Initiated: 08/19/2024
On 01/22/25, at 12:38 PM, Surveyor reviewed a progress note dated 1/6/2025, written at 10:07 AM, IDT (Interdisciplinary Team) FALL: Resident had an unwitnessed fall within her room. Resident was found on the floor on the right side of her bed. She states that she did not hit her head. She was attempting to transfer back into bed. Assessment revealed no injuries. Resident had appropriate footwear on a time of fall. MD (medical doctor) and Notified. Root cause analysis revealed she was attempting to self transfer. Intervention include reeducation regarding using the call light before transfer.
Surveyor requested the fall investigation information from the Facility and reviewed it. Under the category of Statements it reads no statements found. No post fall statements were obtained about the resident or their condition post fall. There was no information documenting when the resident was last seen or last toileted.
Surveyor noted no information on when resident was last rounded or toileted was included in the fall investigation.
On 01/23/25, at 09:50 AM, Surveyor interviewed Registered Nurse (RN)-O regarding when a resident has a fall, what are the next steps. RN-O stated with an unwitnessed fall the nurse would assess to make sure ok, then with help get them up. The nurse then should contact the doctor, family, and case manager if resident has one. Surveyor asked how the fall is investigated and RN-O stated that the Director of Nursing (DON) does post investigation, they look at risk management. Surveyor asked about interviews or statements after
the fall and RN-O stated that there are no interviews unless there are questions about cause of the fall.
On 01/23/25, at 01:40 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about witness statements. DON-B stated they get statements if there are witnesses. For unwitnessed falls the DON speaks with Certified Nursing Assistants (CNA) to determine when they last rounded and if there is any other information.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 1/27/25 at 8:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L. Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get an RN to assess the Level of Harm - Minimal harm or resident. LPN-L would start neuro checks, vital signs and assess range of motion. If everything was ok, potential for actual harm LPN-L would get help to move the resident with the Hoyer lift back into 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 Residents Affected - Some 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.
On 01/27/25, at 10:54 AM, Surveyor informed the Nursing Home Administrator and the DON-B of the concern regarding lack of thorough investigation to include post fall statements and when the resident was last rounded on or toileted.
No additional information was provided.
49435
5.) Resident R12 was admitted to the facility on [DATE REDACTED] with a diagnosis that includes Hemiplegia (muscle weakness or partial paralysis on one side of the body) following stroke affecting right dominant side, Aphasia (language disorder that affects ability to understand and express language), and Vascular Dementia.
Resident R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], documents that Resident R12's cognition is moderately impaired. Resident R12 uses a wheelchair. Resident R12 mobility requires partial to moderate assistance. Resident R12 requires substantial/maximal assistance for transfers. Resident R12 has not had any recent falls since prior MDS assessment.
Resident R12's Fall Risk Care Area Assessment from Resident R12's Annual MDS assessment dated [DATE REDACTED] documents: According to documentation [Resident R12] triggered for falls. [Resident R12] has poor balance [due to] hemiparesis. He receives antidepressant medications which further increases his fall risk. Interventions are in place. No recent falls. Care plan reviewed and updated.
Resident R12's Fall risk care plan initiated on 9/25/22 includes the following pertinent interventions: Remind to use call light for assistance. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. [Resident R12] needs a safe environment with: even floors free from spills and/or clutter; a working and reachable call light, the bed in low position at night; personal items within reach).
Resident R12's fall risk assessment dated [DATE REDACTED] documents Resident R12 is at moderate risk for falls.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Resident R5's progress note entered by Licensed Practical Nurse (LPN)-L, dated 11/24/24 at 10:13 AM documents: [Resident R12] fell out of bed reaching for mints on end table next to bed. [Resident R12] was found face down on right side of Level of Harm - Minimal harm or bed. [Resident R12] stated [Resident R12] did not hit [Resident R12's] head. [Resident R12] stated [Resident R12] was trying to get [Resident R12's] mints. No potential for actual harm injuries were noted. [Resident R12] denied pain. [Director of Nursing (DON)] made aware of situation. MD was made aware of situation. [Range of Motion] was performed and [Within normal limits]. [Resident R12] was Hoyer lifted back Residents Affected - Some in bed and provided mints. Immediate intervention provided was putting mints and items within reach. No concerns noted at this time.
Surveyor reviewed Resident R5's Unwitnessed fall investigation dated 11/24/24. Surveyor noted the following: Predisposing environmental factors, the facility documents that poor lighting was a factor. Resident R12's mental status (whether Resident R12 was oriented to person, place, time or situation) was left blank and nothing was documented in investigation. Predisposing physiological factors (i.e. confused, drowsy, hypotensive, incontinent, weakness, impaired memory, etc.) was left blank and nothing was documented in investigation. Predisposing situation factors (i.e. ambulating without assist, improper footwear, other, etc.) was left blank and nothing was documented in investigation. Predisposing Situation Factors (i.e. using cane, side rails up, using walker, etc.) was left blank and nothing was documented in investigation. Statements-the facility documents no statements found.
On 11/25/24, Interdisciplinary Team (IDT) met and documented the following: [Resident R12] had an unwitnessed fall from bed. [Resident R12] stated that [Resident R12] was attempting to reach mints on [Resident R12's] beside stand. Assessment revealed no injuries. [Vital Signs Stable]. Resident was last rounded on around [9 PM]. [Resident R12] was dry at the time of fall. [Resident R12] is able to make needs known with adequate time given for response. MD, [Power of Attorney], and [Director of Nursing] notified. Root cause analysis revealed that resident was reaching for something to far out of reach. Intervention included encourage resident to keep items frequently needed near for easier reach.
On 11/25/24 a new intervention was added to Resident R12's Fall risk care plan: Encourage resident to keep things frequently needed within reach.
Surveyor noted that investigation did not include whether Resident R12's call light was on at the time of the fall or if the call light was within reach at the time of the fall. Surveyor noted that there were no witness statements regarding the fall. Surveyor noted that multiple sections within the fall investigation template were left blank with no responses. Surveyor noted that poor lighting was identified as a predisposing environmental factor and was not addressed in Resident R12's fall risk interventions.
On 1/23/25 at 1:58 PM, Surveyor interviewed CNA-N. Surveyor asked what CNA-N would be responsible for
after a residents falls. CNA-N stated they would see if the residents was ok and go tell the nurse. CNA-N stated that CNA-N would help Hoyer lift the resident back into the bed or chair if directed by the nurse. Surveyor asked if CNA-N would provide a written statement after a fall. CNA-N stated that they would fill out
a statement sheet from the fall binder.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 1/27/25 at 8:59 AM, Surveyor interviewed (LPN)-L. Surveyor asked if LPN-L could describe what happened when Resident R12 was found on the floor on 11/24/25. LPN-L indicated that a Certified Nursing Assistant Level of Harm - Minimal harm or (CNA) informed LPN-L that Resident R12 was on the floor. LPN-L could not recall which CNA found Resident R12 on the floor. potential for actual harm LPN-L came to Resident R12's room and found that Resident R12 was face down on the side of his bed. LPN-L stated that Resident R12 was reaching for mints when Resident R12 fell . LPN-L stated that Resident R12 did not have any injury and after assessment, Residents Affected - Some Resident R12 was put back into bed with a Hoyer lift. Surveyor asked if the call light was on at time of the fall. LPN-L state LPN-L did not recall. Surveyor asked if Resident R12's call light was within reach. LPN-L stated that LPN-L did not recall. Surveyor asked who saw Resident R12 last and at what time Resident R12 was last seen. LPN-L stated that LPN-L did not recall. Surveyor asked what LPN-L would do if a resident had an unwitnessed fall. LPN-L stated that LPN-L would get a Registered Nurse (RN) to assess the resident. LPN-L would start neuro checks, vital signs and assess range of motion. If everything was ok, LPN-L would get help to move the resident with the Hoyer lift back into 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 Resident 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.
Surveyor noted that the check list gives instructions for staff interviews. Surveyor noted that the completed fall packet is to be taken to the IDT meeting to be reviewed.
On 1/23/25 at 1:52 PM, [TRUNCATED]
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49435
Residents Affected - Few Based on interviews and record review the facility did not ensure 1 (Resident R5) of 1 residents reviewed for colostomy, urostomy or ileostomy services, received care consistent with professional standards of practice.
* Resident R5 was admitted to the facility with a colostomy on 10/25/2024. Resident R5's Physician orders did not contain any orders for the care and treatment of Resident R5's colostomy until an order was placed on January 7th, 2025. There is not consistent documentation that the necessary care and services needed for Resident R5's colostomy were provided between Resident R5's admission to the facility through 1/7/25.
Findings include:
The Facility policy dated 5/1/24 and entitled, Pouch Changes-Colostomy, Urostomy, and Ileostomy, documents, in part: It is the policy of this facility to ensure that residents who require colostomy, urostomy, or ileostomy services receive pouch changes consistent with professional standards of practice to minimize occupational exposure and the resident's skin exposure to fecal matter or urine . Ostomy care will be provided by licensed nurses under the orders of the attending physician. The order should include the type of ostomy, frequency of pouch change, and type of equipment . Procedure: Wash hands . Empty pouch to minimize spillage, as needed . Clean skin around stoma with warm water and wash cloths . Apply ostomy barrier past . Gently press wafer around stoma . Close the end of the pouch with clamp, Velcro, or spout-closure, depending on the type of pouch . Document procedure and findings in the resident's chart.
1.) Resident R5 was admitted to the facility on [DATE REDACTED] with pertinent diagnosis that includes Diverticulitis of Large intestine and Colostomy.
Resident R5's Admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] documents Resident R5's cognition is intact. Resident R5 has an Ostomy.
On 1/22/25 at 10:02 AM, Surveyor interviewed Resident R5. Resident R5 informed Surveyor that Resident R5 was concerned about Resident R5's colostomy care. Surveyor asked Resident R5 what Resident R5's concerns were about colostomy care. Resident R5 stated Resident R5 care of
the ostomy got behind in the beginning of Resident R5's admission to the facility. Resident R5 stated that staff will help Resident R5 with caring for Resident R5's colostomy now.
Resident R5's Ostomy Care plan dated 10/29/24 documents the following interventions: Inspect stoma and peristomal skin location with each pouch exchange. Note and report to MD any changes such as inflammation, bruising, or rashes. Provide ostomy care per facility protocol and as needed.
Surveyor reviewed Resident R5's Certified Nursing Assistant (CNA) Kardex. Surveyor noted that Resident R5's colostomy/colostomy care was not documented anywhere on the CNA Kardex.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0691 Resident R5's physician order with a start date of 1/7/25 documents: Colostomy Appliance Change Convatec #416419 (2 1/4in flange) & Convatec #411804 (2 1/4 in flange, 1 3/4 in stoma opening) weekly and [as needed] one Level of Harm - Minimal harm or time a day every 7 day(s) for Colostomy Care. Cleanse with soap and water, pat dry. Apply skin prep and potential for actual harm appliance AND as needed Cleanse with soap and water, pat dry. Apply skin prep and appliance.
Residents Affected - Few Surveyor noted the physician order with the type of ostomy, frequency of pouch change, type of equipment needed, and cleansing instructions was not placed until 10 weeks after Resident R5's admission.
Surveyor reviewed Resident R5's Treatment Administration Record (TAR) and did not find documentation that Resident R5 was receiving the necessary care and treatment for Resident R5's colostomy until after the physician order was placed on 1/7/25.
On 1/23/25 at 8:46 AM, Surveyor interviewed Registered Nurse (RN)-O. Surveyor asked how often Resident 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 Resident 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 Resident 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 Resident 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 Resident 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 Resident R5 received Colostomy care consistent with professional standards of practice.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011 potential for actual harm Based on interview and record review, the facility did not ensure that residents who require dialysis receive Residents Affected - Few such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 (Resident R485) of 1 residents reviewed for dialysis.
* Resident R485 was admitted to the facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. Assessments were not completed before or after dialysis sessions. No care plan was in place for monitoring and care of Resident R485 related to dialysis and complications. There was no evidence of ongoing communication between the Facility and the dialysis center with each visit.
Findings include:
The Facility Policy titled Hemodialysis implemented 2/15/2023 documents (in part):
Policy:
This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.
Purpose:
The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include:
-The ongoing evaluation of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.
-Ongoing evaluation and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and
-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .
2. The facility will coordinate and collaborate with the dialysis facility to assure that:
a. The resident's needs related to dialysis treatments are met;
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 b. The provision of the dialysis treatments and care of the resident meets current standards for the safe administration of the dialysis treatments; Level of Harm - Minimal harm or potential for actual harm c. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team; and Residents Affected - Few d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff.
3. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes.
4. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to:
a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility;
b. Physician/treatment orders, laboratory values, and vital signs .;
7. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications .
10. The facility will ensure that the physician's orders for dialysis include:
a. The type of access for dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location.
b. The dialysis schedule.
c. The nephrologist name and phone number.
d. The dialysis facility name and phone number.
e. Transportation arrangements to and from the dialysis facility.
f. Any medication administration or withholding of specific medications prior to dialysis treatments.
g. Any fluid restriction if ordered by the physician.
11. The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent,
the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 13. Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled. Change dressing to site only per the dialysis facility's direction . Level of Harm - Minimal harm or potential for actual harm 1.) Resident R485 was admitted to the facility on [DATE REDACTED] with diagnoses that include end stage renal disease, chronic obstructive pulmonary disease, human immunodeficiency virus [hiv] disease, systolic (congestive) heart Residents Affected - Few failure, chronic pain syndrome, anxiety disorder, depression, spinal stenosis at cervical region, and mood disorder due to known physiological condition with depressive features.
Resident R485's Admission Minimum Data Set (MDS) with an assessment reference date of 1/17/2025 indicated Resident R485 had a Brief Interview for Mental Status score of 15 (cognitively intact). Resident R485 does not have an activated guardian or power of attorney. Resident R485 scored a 24 on the patient depression questionnaire indicating severe depression present. Resident R485's MDS was coded that for toileting Resident R485 has an indwelling catheter and is always continent of bowel. Resident R485 was also coded as receiving dialysis.
Resident R485 was marked on the Facility's roster matrix as receiving dialysis. Surveyor was reviewing Resident R485's electronic medical record (EMR) and read the following progress note written on 1/13/2025, at 1:04 PM, Clinical Summary: Resident admitted to facility via with ambulance service on stretcher from Mount [NAME] . Has hx (history of) ESRD (end stage renal disease). On HD (hemodialysis) 3 times weekly; Tues (Tuesday), Thur (Thursday),Sat (Saturday) .
Surveyor was unable to locate any physician orders, assessments related to dialysis sessions, care plan related to dialysis or communication with the dialysis center in the electronic medical record.
The Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement dated 10/2/2024, between the Facility and Wisconsin Renal Care Group documents in part:
B. Obligations of Operator's Long Term Care Facility
1. Information Sharing. For the purposes of care coordination, in advance of each Resident's dialysis treatment, Long Term Care Facility shall furnish all information and documentation necessary for Dialysis Facility to provide safe and appropriate care, including any information reasonably requested by Dialysis Facility .
On 01/23/25, at 09:50 AM, Surveyor interviewed Registered Nurse (RN)-O regarding dialysis communication. Per RN-O, a resident is sent to dialysis with an information sheet, Resident R485 leaves early so the NOC (night shift) nurse would complete the form for Resident R485. The resident brings back the form and medical records gets it to upload. Surveyor asked about pre/post assessments for dialysis. Per RN-O, Resident R485 gets picked up before RN-O is here. After dialysis RN-O will look at Resident R485, but Resident R485 likes to go straight to bed to be left alone and will call if Resident R485 needs help.
On 01/23/25, at 01:34 PM, Surveyor interviewed Director of Nursing (DON)-B regarding communication with
the dialysis center and was informed that there is a paper form and after the resident returns, it will be scanned into the electronic chart. Surveyor requested the forms for Resident R485. Surveyor asked about a care plan and orders specific to Resident R485's dialysis needs. DON-B stated DON-B would review Resident R485's medical record and get back to Surveyor.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 Surveyor was unable to locate any physician order or care plan for how often or when dialysis occurs in Resident R485's electronic medical record (EMR). Resident R485 had nothing added for care and monitoring of the dialysis site. Level of Harm - Minimal harm or Surveyor noted no documentation could be located for assessments completed after Resident R485 returned from potential for actual harm dialysis.
Residents Affected - Few The Facility provided one Dialysis Communication Form dated 1/16/2025 that had the Pre-dialysis information section completed, and the dialysis center information completed. The post-dialysis information section was left blank. Surveyor noted that Resident R485 would have received dialysis 6 times prior to surveyor reviewing the information and only one form was provided that was partially completed.
Surveyor noted that according to the State Operations Manual, there is a requirement for ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments are received at a certified dialysis facility.
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 Resident R485 had no physician orders put in for dialysis times and days, monitoring before and after and that no care plan specific to Resident R485 was completed for dialysis.
No additional information was provided.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Potential for minimal harm 42037
Residents Affected - Many 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 well-being of each resident.
* 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47094
Residents Affected - Few Based on interview and record review the facility did not ensure nursing staff had the specific competencies and skill sets necessary to care for resident's needs affecting 1 (Resident R29) of 12 residents reviewed.
Resident R29 indicated Resident Assistant (RA)-T pivots transfers Resident R29 into a wheelchair and takes Resident R29 outside to smoke. RA-T is employed with the community based residential facility (CBRF) and is not a certified nursing assistant (CNA) or certified to care for residents in the long-term care facilities. Resident R29 was assessed to require
the use of a sit to stand mechanical lift for transfers.
Findings include:
Resident R29 was admitted to the facility on [DATE REDACTED] and has diagnoses that include multiple sclerosis, generalized anxiety disorder, and recurrent depressive disorder.
Resident R29's quarterly minimum data set (MDS) dated [DATE REDACTED] indicated Resident R29 had intact cognition with a Brief
Interview for Mental Status (BIMS) score of 15 and the facility assessed Resident R29 as being dependent on 1 staff member for personal and toileting hygiene, lower body dressing, and putting on/off footwear, and Resident R29 had impairments to both right and left side upper and lower extremities. Resident R29 required a sit to stand device for transferring and required max assist with 1 staff member for repositioning in bed.
On 1/23/2025, at 9:00 AM, Surveyor observed Resident R29 lying in bed watching TV. Surveyor asked Resident R29 if Resident R29 got out of bed. Resident R29 replied Resident R29 only really gets out of bed when Resident R29 goes out to smoke. Resident R29 stated whenever RA-T is on duty, RA-T makes it a point to come and get Resident R29 out of bed by helping her stand up by putting RA-T arms around her and pivots Resident R29 into the wheelchair. Resident R29 stated RA-T stays with Resident R29 outside and then will bring Resident R29 back into the facility and pivots Resident R29 back into bed.
Surveyor reviewed Resident R29's care plan and CNA care card and notes Resident R29's transfer status is documented as:
-Transfer: Resident R29 requires sit to stand for transfers.
Surveyor reviewed the facility staffing list and noted RA-T was listed as a RA for the CBRF side of the facility not the skilled nursing home side of the building.
On 1/23/2025, at 9:44 AM, Surveyor interviewed Director of Nursing (DON)-B who stated RA-T is not a CNA and works in the CBRF part of the facility. Surveyor asked if RA-T would ever care for a resident in the long term care side. DON-B stated if a CNA requested assistance RA-T is able to assist, but RA-T would not assist a resident alone. Surveyor requested a job description for the RA position.
Surveyor reviewed the RA position description for the CBRF and notes that there is no indication a RA would assist residents residing in the long term care area or is able to assist with resident care if asked by a CNA in
the long term care area.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726 RA-T was on vacation at the time of the survey and was not available for an interview.
Level of Harm - Minimal harm or On 1/27/2025, at 10:38 AM, Surveyor shared concern with DON-B and Nursing Home Administrator (NHA)-A potential for actual harm that Resident R29 states RA-T assists Resident R29 into the wheelchair with a pivot transfer and takes Resident R29 outside to smoke. Resident R29 is assessed to need a sit to stand mechanical lift for transfers. RA-T is employed as a RA in the CBRF Residents Affected - Few side of the facility and is not a CNA or employed to assist residents on the long term care side of the building. Surveyor also shared there is no indication in the RA job description that would allow a RA to assist a CNA if requested with long term care residents.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0732 Post nurse staffing information every day.
Level of Harm - Potential for 42037 minimal harm Based on observation, interview, and record review, the facility did not ensure that the daily nurse staff Residents Affected - Many 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011
Residents Affected - Few Based on interview and record review, the Facility did not ensure the accurate and safe administration of medication for 1 Resident (Resident R485) of 12 residents reviewed.
Resident R485 has a physician order for Epoetin Alfa Injection Solution 4000 UNIT/ML. Inject 1 vial subcutaneously at bedtime every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for anemia related to human immunodeficiency virus [hiv] disease. This medication was not available to be given after Resident R485 admitted to
the Facility, resulting in 5 missed doses.
Findings include:
Resident R485 was admitted to the facility on [DATE REDACTED], with diagnoses that include, human immunodeficiency virus [hiv] disease.
Resident R485's Admission Minimum Data Set (MDS) with an assessment reference date of 1/17/2025 documents Resident R485 had a Brief Interview for Mental Status score of 15, indicating Resident R485 is cognitively intact. Resident R485 scored a 24 on the patient depression questionnaire indicating severe depression present.
Resident R485's progress note dated 1/14/2025, at 8:17pm, documents Medication Administration Note . Epoetin Alfa Injection Solution 4000 UNIT/ML . On order.
On 1/16/2025, at 10:34 PM, Medication Administration Note . Epoetin Alfa Injection Solution 4000 UNIT/ML . not available.
On 1/23/2025, at 11:37 PM, Medication Administration Note . Epoetin Alfa Injection Solution 4000 UNIT/ML . pending delivery.
Medication Administration Record for Resident R485 documents the medication should have been administered on 1/14/25, 1/16/25, and 1/23/25 all which the reason why not given was recorded above. The medication should also have been given 1/18/25 and 1/21/25 these were left blank, indicating that the medication was not given.
Surveyor notes there is no documentation the physician or pharmacy were contacted regarding the unavailable medication.
On 01/23/25, at 09:50 AM, Surveyor interviewed Registered Nurse (RN)-O who stated that they are waiting for the pharmacy to deliver the medication. RN-O stated when a medication is not available a nurse should update the physician that they don't have it.
On 01/23/25, at 01:37 PM, Surveyor interviewed Director of Nursing (DON)-B about what happens if nurses don't have a medication to give. DON-B stated the nurses should update the doctor and contact the pharmacy to figure out why the medication is not here.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 On 01/27/25, at 9:54 AM, Surveyor requested a policy regarding missed medication doses from DON-B and was told that there is not a policy that addresses missed doses. DON-B state the protocol is to call the Level of Harm - Minimal harm or doctor, call the pharmacy, check contingency for the medication, if it is not in contingency then make the potential for actual harm pharmacy send it.
Residents Affected - Few On 01/27/25, at 10:50 AM, Surveyor informed Nursing Home Administrator-A and the DON-B of the concern regarding Resident R485 missed 5 doses of Epoetin Alfa Injection Solution 4000 UNIT/ML and the lack of documentation as to whether the physician or pharmacy was ever updated on the issue.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47094
Residents Affected - Few Based on interview and record review, the facility did not act upon the pharmacy medication regimen review reports when received. This was observed with 1 (Resident R21) of 5 resident medication reviews.
Resident R21's monthly pharmacy reviews noted a recommendation reported on 9/10/2024 and 11/11/2024 (same concern from 9/10/2024 recommendation). There was no documentation the attending physician acted upon
the recommendations from pharmacy until Surveyor requested to see the physician signed reviews that were dated the same day requested.
Findings include:
Resident R21 was admitted to the facility on [DATE REDACTED] and has diagnoses that include dementia, traumatic brain injury, epilepsy (seizure disorder), anxiety, and depression. Resident R21 is enrolled to receive Hospice services and care.
On 1/23/2025, at 3:32 PM, Surveyor requested to see Resident R21's pharmacy medication review recommendations for the last six months.
On 1/27/2025, at 10:07 AM, Surveyor received Resident R21's pharmacy medication review recommendations. Surveyor noted the documents were not signed by a physician and requested signed documents. Director of Nursing (DON)-B stated DON-B was looking for the signed sheets and would have to look in medical records.
Resident R21's pharmacy medication review dated 9/10/2024 documents pharmacist recommendations that include:
1. Resident R21 is on PRN (as needed) Ativan. Per CMS (Centers for Medicaid/Medicare Services) all PRN psych medications must have a stop date after 14 days. Please add stop date and revisit order every 14 days.
2. Resident R21 is on zonisamide suspension 200 mg (milligrams) every day and 100 mg twice a day. Zonisamide is dosed every day - twice a day. Please change to 400 mg every day or 200mg twice a day to reduce medication pass burden.
3. Resident R21 is on Topiramate solution 6 ml (milliliters) three times a day. Topiramate is dosed twice a day. Please change to 9 ml twice a day to reduce medication pass burden.
Surveyor notes there is no documentation the recommendations were acted upon or the physician was consulted with the recommendations.
Resident R21's pharmacy medication review dated 11/11/2024 documents pharmacist recommendation that includes:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756 1.Resident R21 has an order for lorazepam 0.5 mg every 1 hour as needed. PRN psychotropics orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and Level of Harm - Minimal harm or indicate the duration for the PRN order. potential for actual harm Surveyor notes there is no documentation that the recommendation was acted upon, or the physician was Residents Affected - Few consulted with the recommendation.
Surveyor reviewed Resident R21's medication orders and noted that the recommendations by the pharmacist were not changed for Resident R21's: lorazepam, zonisamide, or topiramate per recommendation on 9/10/2024.
On 1/27/2025, at 11:31 AM, Surveyor received Resident 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 Resident R21's medication reviews were not reviewed or looked at monthly. Surveyor shared concern Resident 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011 potential for actual harm Based on interview and record review, the Facility did not ensure monitoring for adverse reactions of high Residents Affected - Few risk medications for 2 residents (Resident R31 and Resident R485) of 5 residents reviewed for unnecessary medications.
*Resident R31 has orders for Eliquis (anticoagulant) twice daily for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity and Furosemide (diuretic) once daily for hypertension. The Facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant or diuretic.
*Resident R485 has orders for Apixaban (anticoagulant) twice daily for end stage renal disease and Furosemide (diuretic) once daily for hypertension. The Facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant or diuretic.
Findings include:
The Facility Policy titled High Risk Medications implemented 10/1/2023 documents (in part):
Policy:
This facility recognizes that some medications are associated with greater risks of adverse consequences than other medications. These high-risk medications can include antidiabetics, psychotropics, cardiac medications, opioids, diuretics, antibiotics and any other medication that can bear a heightened risk. This policy addresses the facility's collaborative, systematic approach to managing high risk medications for efficacy and safety .
Policy Explanation and Compliance Guidelines .:
6. The resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications given.
7. The resident's plan of care shall include interventions to minimize risk of adverse consequences.
1) Resident R31 was admitted to the facility on [DATE REDACTED] from the hospital with diagnoses which include, in part, chronic migraine without aura, morbid (severe) obesity, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, hypertension, major depressive disorder, and type 2 diabetes mellitus.
Resident R31's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/15/2024 indicated Resident R31 had a Brief Interview for Mental Status score of 14, indicating Resident R31 is cognitively intact; frequently incontinent of bladder and always continent of bowel.
Resident R31 has orders for:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757 -Eliquis Oral Tablet 5 MG (milligrams), give 1 tablet by mouth two times a day for Blood Thinner related to chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Level of Harm - Minimal harm or potential for actual harm -Furosemide Tablet 20 MG, give 1 tablet by mouth one time a day for Edema related to essential (primary) hypertension. Residents Affected - Few Surveyor reviewed Resident R31's electronic medical record and noted there is no person-centered care plan to monitor for adverse side effects related to the use of an anticoagulant and diuretic.
On 01/27/25, at 11:28 AM, Surveyor interviewed Director of Nursing (DON)-B regarding Resident R31'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 yes both should have been care planned for Resident R31.
2.) Resident R485 was admitted to the facility on [DATE REDACTED], 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.
Resident R485's Admission Minimum Data Set (MDS) with an assessment reference date of 1/17/2025 indicated Resident R485 had a Brief Interview for Mental Status score of 15, indicating Resident R15 is cognitively intact. Resident R485 does not have an activated power of attorney. Resident R485 scored a 24 on the patient depression questionnaire indicating severe depression present. Resident R485's MDS documents Resident R485 has an indwelling catheter and is always continent of bowel, and receiving dialysis.
Resident 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 Resident R485's electronic medical record and noted there is no person-centered care plan for Resident 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 Resident 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 Resident R485.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38253 potential for actual harm Based on observation, interview, and record review, the facility did not maintain an infection prevention and Residents Affected - Many control program to help prevent the development and transmission of communicable diseases and infections potentially affecting all 39 residents in the facility and Enhanced Barrier Precautions were not in place or followed for 2 (Resident R37 and Resident R8) of 2 residents observed receiving wound care.
*Enhanced Barrier Precautions (EBP) were not posted on doors as required for residents with invasive devices or wounds.
*Rates of infection were not calculated and documented monthly to monitor trends of infection.
*Resident R37 had an indwelling urinary catheter in place and wound care was completed with no Enhanced Barrier Precautions in place.
*Resident R8 had wound care completed and staff did not follow the Enhanced Barrier Precautions.
Findings include:
The facility policy and procedure titled Enhanced Barrier Precautions dated 12/23/2022 documents: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.
Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (Multidrug-Resistant Organisms) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).
Policy Explanation and Compliance Guidelines:
1. Prompt recognition of need: .
c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.
2. Initiation of Enhanced Barrier Precautions -
a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders.
b. An order for enhanced barrier precautions will be obtained for residents with any of the following:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 i. Wounds (i.e., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis Level of Harm - Minimal harm or catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known potential for actual harm to be infected or colonized with a MDRO.
Residents Affected - Many 3. Implementation of Enhanced Barrier Precautions -
a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray.
b. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room).
c. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.
d. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.
e. Provide education to residents and visitors.
4. High-contact resident care activities include:
a. Dressing
b. Bathing
c. Transferring
d. Providing hygiene
e. Changing linens
f. Changing briefs or assisting with toileting
g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes
h. Wound care: any skin opening requiring a dressing
5. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activity.
7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical devices removed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 1.) On 1/22/2025, at 9:14 AM, during the entrance conference with Nursing Home Administrator (NHA)-A, Surveyor requested a list of residents in any type of isolation precautions. NHA-A stated the facility had Level of Harm - Minimal harm or residents on Enhanced Barrier Precautions (EBP) and no other isolation precautions were in the building. potential for actual harm NHA-A provided a list of residents on EBP. Eleven residents were listed as being on EBP: Resident R18, Resident R10, Resident R14, Resident R23, Resident R5, Resident R11, Resident R485, Resident R40, Resident R25, Resident R8, and Resident R24. Residents Affected - Many
On 1/22/2025, at 1:14 PM, Surveyor observed every room of the facility to verify residents on the EBP list had a sign on the door indicating the precautions.
-Resident R1 had an EBP sign on the door but was not on the EBP list.
-Resident R29 had an EBP sign on the door but was not on the EBP list.
-Resident R10 had an EBP sign on the door and was on the EBP list.
-Resident R11 and Resident R23, roommates, had an EBP sign on the door and were on the EBP list.
-Resident R40 had an EBP sign on the door and was on the EBP list.
Surveyor noted 5 rooms had EBP signs on the door of the room when 9 rooms were on the EBP list.
Surveyor reviewed the roster matrix for each individual resident of the facility. Per the roster matrix, 17 residents qualified for EBP. Surveyor noted a total of 14 rooms should have had EBP signs posted on the door and only 5 rooms had EBP signs posted with one room, Resident R29, not needing an EBP sign to be posted.
-Resident R1 had gastrostomy tube, had an EBP sign posted on the door, but was not on the EBP list.
-Resident R29 had an EBP sign posted on the door but did not have any indicators to be in EBP and was not on the EBP list.
-Resident R38 had a gastrostomy tube, did not have an EBP sign posted on the door, and was not on the EBP list.
-Resident R10 had an indwelling urinary catheter, an EBP sign posted on the door, and was on the EBP list.
-Resident R25 had a wound and was on the EBP list but did not have an EBP sign posted on the door.
-Resident R37 had an indwelling urinary catheter, did not have an EBP sign posted on the door, and was not on the EBP list.
-Resident R24 had a wound and was on the EBP list but did not have an EBP sign posted on the door.
-Resident R8 had a wound and was on the EBP list but did not have an EBP sign posted on the door.
-Resident R18 had an ostomy and was on the EBP list but did not have an EBP sign posted on the door.
-Resident R14 had an ostomy and was on the EBP list but did not have an EBP sign posted on the door.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 -Resident R39 had a dialysis port, did not have an EBP sign on the door, and was not on the EBP list.
Level of Harm - Minimal harm or -Resident R5 had an ostomy and was on the EBP list but did not have an EBP sign posted on the door. potential for actual harm -Resident R33 had an indwelling urinary catheter, did not have an EBP sign on the door, and was not on the EBP list. Residents Affected - Many -Resident R11 had an indwelling urinary catheter, an EBP sign posted on the door, and was on the EBP list.
-Resident R23 had an ostomy and an indwelling urinary catheter, an EBP sign posted on the door, and was on the EBP list.
-Resident R40 had an indwelling urinary catheter, an EBP sign posted on the door, and was on the EBP list.
-Resident R485 had an indwelling urinary catheter and a dialysis port and was on the EBP list but did not have an EBP sign posted on the door.
-Resident R41 had a gastrostomy tube, did not have an EBP sign posted on the door, and was not on the EBP list.
In an interview on 1/22/2025, at 1:14 PM, Surveyor asked Certified Nursing Assistant (CNA)-N how staff knew if a resident was in EBP. CNA-N stated there is a sign on the door that tells you what PPE you should wear. CNA-N stated there were not any residents right now that were in isolation. Surveyor observed the rooms in the hallway CNA-N was standing in did not have any signs for EBP for any residents when six of
the rooms should have had EBP signs posted.
In an interview on 1/22/2025, at 1:20 PM, Surveyor asked Licensed Practical Nurse (LPN)-V where gowns were located for residents in isolation. LPN-V stated the gowns are located in the linen room down the hallway. LPN-V did not state isolation gowns were located in the first closet inside the door of the resident room.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 In an interview on 1/23/2025, at 9:09 AM, Surveyor asked Director of Nursing (DON)-B, who was also the facility Infection Preventionist, what the qualifications were for individuals that should be in EBP. DON-B Level of Harm - Minimal harm or stated anybody who has an ostomy, an indwelling urinary catheter, an external line of some kind, and potential for actual harm anyone with a wound must be in EBP. DON-B stated if you are spending an extended period of time doing anything with the resident, the staff needs to wear a gown and gloves. DON-B stated if staff is performing Residents Affected - Many cares with a resident, they need to be wearing a gown and gloves while doing any of those things. Surveyor asked DON-B how staff knew when they should be wearing a gown and gloves for those residents. DON-B stated all residents in EBP should have a sign on the door and the gowns are located in the first closet inside
the room. DON-B stated they are trying to keep the hallways clear so they use the closet right inside the door of the resident's room and the garbage can is in the room. Surveyor shared with DON-B the observations of multiple rooms with no EBP sign posted on the doors and the interviews with CNA-N and LPN-V; CNA-N knew there should be signs posted on the doors of residents in isolation but with no signs posted, was unaware of who was in EBP and LPN-V was not aware gowns were available in resident room closets. Surveyor reviewed the EBP list with DON-B and shared the concern the list was not inclusive of all residents that should be in EBP. DON-B stated Resident R29's roommate that had been discharged was in EBP and the sign should be taken down. DON-B stated Resident R39 should be added to the EBP list because Resident R39 now has a wound. Surveyor shared with DON-B Resident R39 had a dialysis port so should have already been on the EBP list. DON-B stated DON-B was not sure if the residents receiving dialysis (Resident R39 and Resident R485) had a port or a fistula so that would determine if they needed to be in EBP. DON-B stated Resident R40's indwelling urinary catheter was removed yesterday so no longer needed to be in EBP. DON-B stated Resident R37 developed a wound yesterday so needed to be added to the EBP list. Surveyor shared with DON-B Resident R37 had an indwelling urinary catheter so should already be in EBP. DON-B stated DON-B had gone through the facility yesterday and placed EBP signs on
the doors that needed to be posted for the majority of the rooms and would fix the rest that day.
2.) The facility policy and procedure titled Infection Surveillance dated 5/16/2023 documents: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. 14. Formulas used in calculating infection rates will remain constant for a minimum of one calendar year, and will require discussion in QAA (Quality Assessment and Assurance) meetings before changes in the formulas are made.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 In an interview on 1/23/2025, at 9:09 AM, Surveyor asked Director of Nursing (DON)-B, who is also the facility Infection Preventionist, how infections are monitored in the facility. DON-B stated DON-B reviews Level of Harm - Minimal harm or charting, new orders, and 24-hour reports to see if any residents were started on an antibiotic. Surveyor potential for actual harm asked DON-B if there is a line list of residents with symptoms of infection but not on an antibiotic. DON-B stated no, DON-B does not keep a line list for residents with symptoms but does keep a change of condition Residents Affected - Many sheet that DON-B updates with information. DON-B stated DON-B looks at charting or the nurses tell DON-B if someone has a cough. DON-B stated DON-B keeps a watch on those residents in DON-B's notes to follow up on every day. DON-B stated if there were a lot of residents in a row that had the same symptoms, DON-B would realize it and then would start a line list. DON-B stated DON-B keeps a notebook and that is why there is a paper copy before it is transferred into a computer list. Surveyor asked DON-B if monthly infection rates were calculated. DON-B stated at the end of the month DON-B looks to see what happened that month and reports it to QAPI (Quality Assurance and Performance Improvement). DON-B stated if urinary tract infections were up, DON-B would do education on peri care. Surveyor asked DON-B to provide the last five months of infection rates to review. DON-B stated DON-B did not have the actual infection rates available and would have to dig them up. Surveyor asked DON-B if the infection rates were reported to Quality Assurance and Assessment (QAA). DON-B stated no, the rates were not reported. Surveyor requested from DON-B the last five months of infection rates. At 2:27 PM, DON-B stated DON-B did not have access to the program they had been using so does not have the rates of infection broken down by type of infection. DON-B stated DON-B will be doing that in the future.
On 1/23/2025, at 2:25 PM, Surveyor shared with Nursing Home Administrator (NHA)-A DON-B did not provide the rates of infection for the last 5 months and the concern the surveillance is not effective in monitoring how infections are presented in the facility.
3.) Resident R37 was admitted to the facility on [DATE REDACTED] with diagnoses of neuromuscular dysfunction of the bladder requiring an indwelling urinary catheter.
On 1/15/2025, at 9:21 PM in the progress notes, nursing documented Resident R37 had an open area to the buttocks measuring 0.3 cm (centimeters) x 0.3 cm. The site was cleansed and a 4x4 dressing was applied.
On 1/22/2025, at 1:16 PM, Surveyor observed a Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN)-V outside of Resident R37's room. LPN-V had the treatment cart and got gauze out of the cart. The CNA and LPN-V entered Resident R37's room. Surveyor noted Resident R37 did not have any isolation or Enhanced Barrier Precaution (EBP) signs posted on the door. At 1:20 PM, LPN-V came out of Resident R37's room. Surveyor asked LPN-V if LPN-V did wound care to Resident R37. LPN-V stated yes, LPN-V did wound care to Resident R37. Surveyor asked LPN-V if Resident R37 had an indwelling urinary catheter. LPN-V stated yes. Surveyor asked LPN-V what personal protective equipment (PPE) LPN-V wore while doing the dressing change to Resident R37. LPN-V stated LPN-V wore gloves. Surveyor asked LPN-V if LPN-V wore a gown during the dressing change. LPN-V stated no, just gloves. Surveyor asked LPN-V where a gown would be found if a gown was needed. LPN-V stated the gowns are in the linen room down the hallway. Surveyor noted Resident R37 had an indwelling urinary catheter and a wound; no EBP sign was posted on the door and LPN-V did not know Resident R37 should have been in EBP due to
the wound and urinary catheter.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 In an interview on 1/23/2025, at 9:09 AM, Surveyor asked Director of Nursing (DON)-B, who was also the facility Infection Preventionist, what the qualifications were for individuals that should be in EBP. DON-B Level of Harm - Minimal harm or stated anybody who has an ostomy, an indwelling urinary catheter, an external line of some kind, and potential for actual harm anyone with a wound must be in EBP. DON-B stated if you are spending an extended period of time doing anything with the resident, the staff needs to wear a gown and gloves. DON-B stated if staff is performing Residents Affected - Many cares with a resident, they need to be wearing a gown and gloves while doing any of those things. Surveyor asked DON-B how staff knew when they should be wearing a gown and gloves for those residents. DON-B stated all residents in EBP should have a sign on the door and the gowns are located in the first closet inside
the room. DON-B stated they are trying to keep the hallways clear to they use the closet right inside the door of the resident's room and the garbage can is in the room. Surveyor shared with DON-B the observation and
interview with LPN-V; LPN-V was not aware Resident R37 should have been in EBP and did not know there were gowns in the first closet inside the resident room door. DON-B stated Resident R37 developed a wound yesterday so needed to be added to the EBP list. Surveyor shared with DON-B Resident R37 had an indwelling urinary catheter so should already be in EBP. DON-B agreed Resident R37 should have been in EBP.
49845
4.) Resident R8 was admitted to the facility on [DATE REDACTED] with diagnoses which include malnutrition, osteoporosis, peripheral vascular disease, vascular dementia, and major depressive disorder. Resident R8 has a Legal Guardian. Resident R8's Annual Minimum Data Set (MDS), dated [DATE REDACTED], documents Resident R8 has a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment; did not exhibit behavior concerns; had range of motion impairment in upper and lower extremities, partial/moderate assistance with rolling left to right, and at risk for pressure ulcers.
Resident R8's most recent MDS is a Significant Change, dated 10/28/2024, and documents a BIMS score of 01, indicating severe cognitive impairment; no behavior concerns; on a scheduled pain medication regimen, prognosis of life expectancy less than 6 months, at risk for pressure ulcers, has one or more unhealed pressure ulcer, 1 slough and/or eschar pressure ulcer, 1 unstageable deep tissue injury, skin tears, receiving pressure ulcer care, surgical wound care, and is now on hospice.
Surveyor reviewed the Facility's document titled, Resident Matrix, and noted Resident R8 is documented to have a pressure ulcer that was not present on admission.
On 01/22/2025, at 09:47 AM, Surveyor noted no Enhanced Barrier Precautions (EBP) sign on Resident R8's door. Surveyor spoke with Hospice RN-K. Hospice RN-K indicated Resident R8 has daily hospice visits, has 2 pressure ulcers that are treated by the Facility along with the wound care team, and has multiple other not opened pressure ulcers. Hospice RN-K indicated there are too many to count. Hospice RN-K indicated Resident R8 is on scheduled end of life medications.
On 01/23/2025, at 10:18 AM, Surveyor was waiting for nurse to observe wound care and noted Resident R8 to now have an EBP sign on Resident R8's door.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 On 01/23/2025, at 11:57 AM, Surveyor observed LPN-F provide wound care for Resident R8, with Hospice CNA-I assisting. Surveyor observed LPN-F perform wound care on Resident R8 only wearing gloves. Surveyor asked LPN-F Level of Harm - Minimal harm or if Resident R8 is on any precautions. LPN-F indicated Resident R8 is not on any precautions. Surveyor asked about the sign on potential for actual harm Resident R8's door. Hospice CNA-I went to look at Resident 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 Residents Affected - Many door. LPN-F indicated LPN-F realizes Resident 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm or 38253 potential for actual harm Based on interviews and record reviews, the facility did not ensure residents received the influenza Residents Affected - Few immunization and the pneumococcal immunization for 2 (Resident R37 and Resident R23) of 5 residents reviewed for immunizations.
*Resident R37 consented to the influenza immunization and did not receive it.
*Resident 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.) Resident 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 Resident 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 Resident R37's medical record.
2.) Resident 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 Resident 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 Resident R23's medical record.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 53 525686 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883 On 1/23/2025, at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern Resident R37 had not received the influenza vaccine and Resident R23 had not received the pneumococcal vaccine when both had Level of Harm - Minimal harm or provided consent to receive the vaccines. potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 53 525686