Muskego Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Muskego Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 21, 2022

  Based on interviews, record review, and policy review, the facility failed to protect 2 residents (R) from physical abuse. R4 has a diagnosis of dementia and a history of striking out at his roommates while residing in other facilities. This information was disclosed to the facility prior to his admission. Despite this information, R4 shared a room with R6. Records indicate R4 sat on R6's chest and that R6 felt R4 was going to kill him. After that incident, the facility allowed R9 to share a room with R4. R4 punched R9 in the face 2 times while R9 was sleeping. Staff interview found that R4 was easily agitated and had instigated altercations with other residents. Facility failure to protect R6 and R9 from abuse created a finding of immediate jeopardy that began on 6/13/22. […]

• Immediate jeopardy, isolatedF689Nov 21, 2022

  Based on interview, record review, document review, and facility policy review, the facility failed to ensure that the environment was free of hazards for 2 of 12 residents reviewed. Resident (R) 2, while in his wheelchair, entered an unlocked, unsupervised stairwell on the 2nd floor and fell down the stairs. R2 was found at the bottom of the stairs at 11:00PM on 08/21/22 by the night nurse with his wheelchair on top of him. Although the length of time R2 laid in the stairwell is unknown, it was found that R2 missed a meal and 2 medication passes. There was no lock and/or alarm on the door to the stairwell. R2 was transported the emergency room and was found to have cut on his face, black eye, bump on his head, fractured femur near his hip and two fractured vertebrae. […]

• Actual harm, isolatedF686Jul 9, 2026

  Based on observation, interview and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing for 3 (R1, R15, R16) of 4 residents reviewed for pressure injuries from a sample of 12 residents. *On 2/26/25, R1 was admitted to the facility and assessed to be at high risk for the development of pressure injuries. On 7/23/25 during wound rounds R1was assessed to have developed a facility acquired, unstageable pressure injury to the left heel. R1's care plan did not include an intervention to wear a pressure relieving boot to the left foot until 12/05/25. […]

• Actual harm, isolatedF686Jun 8, 2022

  Based on interview, observation and record review, the facility did not ensure 1 (R17) of 2 residents reviewed for pressure injuries received care, consistent with professional standards of practice, to prevent pressure ulcers and not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. * R17 had bilateral hand contractures. In January and February of 2022, R17 developed a pressure injury to her left hand (1/21/22), third finger due to the contracture. […]

• No harm, potential for more than minimal, widespreadF730Jul 9, 2026

  Based on interview and record review, the facility did not ensure that 5 of 5 Certified Nursing Assistants (CNAs) reviewed had an annual performance review completed every twelve months.CNA-E, CNA-G, CNA-H, CNA-I and CNA-J did not have an annual performance review.This deficient practice had the potential to affect all 36 residents residing in the facility as the CNAs work with residents throughout the facility.Findings include:The facility policy, entitled Competency Evaluation dated as revised 8/21/24, documents:Guideline: It is the guideline of this facility to evaluate each employee to ensure they meet appropriate competencies and skills for performing their job.Explanation and Compliance Guidelines:1.The knowledge and skills required among staff to meet residents' needs are determined… […]