Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lindengrove Mukwonago during CMS and state inspections, most recent first.
Food service safety practices were not followed in the main kitchen and a satellite kitchen. The FSM was observed handling food without a beard restraint, a blender blade still had food residue when it was reused for a second puree, food debris was present on the kitchen floor and under equipment, and an opened salsa container remained stored with ready-to-serve condiments. In a rehab kitchen, a refrigerator was found at 67 degrees with milk, pudding, Jello, creamer, and cut fruit inside, and staff were unaware of how long it had been out of range.
Failure to Provide Written Transfer and Bed Hold Notices: Surveyors found that written notice of the reason for hospital transfer/discharge and bed hold policy was not provided for four residents reviewed. One resident had severe cognitive impairment and an activated POA, two residents had hospital transfers for medical issues including surgery and respiratory concerns, and another resident with moderate cognitive impairment and an activated POAHC was sent out after becoming lethargic, febrile, and hyperglycemic. The facility’s form also lacked the Ombudsman’s email address, and records showed only verbal notification or no notice at all.
A resident with severe cognitive impairment and a history of falls did not receive required supervision and assistance devices, specifically Dycem on the wheelchair cushion, as outlined in the care plan. Multiple observations confirmed the absence of Dycem, and staff were unaware of its use. After the resident experienced a fall, the facility's investigation was incomplete, lacking staff statements and a root cause analysis.
A resident with ESRD, chronic respiratory failure, COPD, CHF, A-fib, dementia, and severe cognitive impairment was observed with a white pill and about four pills left on the breakfast tray beside the bed. The chart had no prescriber order for self-administration and the self-administration assessment was blank, while staff interviews confirmed the resident did not self-administer meds and the DON said the resident could not take her own medication.
Code status was not clearly documented for a resident with an activated POA and multiple chronic conditions. Although a signed State DNR form was in the EMR, the resident's code status was not listed under the resident's name and there was no current physician DNR order. RN and DON both confirmed the missing documentation, and the DON found only a discontinued DNR order in the chart.
Failure to Provide Pressure Injury Care and Prevention A resident at high risk for pressure injuries developed a right ankle/foot wound that was not consistently or accurately staged, was not promptly reflected in the care plan, and progressed from a blister to a stage 3 PI with infection and pain requiring antibiotics. The resident also refused heel boots multiple times, and the record did not consistently show an alternative offloading intervention. A second resident developed a new pressure wound to the gluteus that was not comprehensively assessed by an RN until later, and the care plan was not updated to include wound-related interventions.
A facility failed to provide appropriate Foley catheter care for two residents. Surveyors observed one resident’s catheter bag on the floor without a protective barrier, and record review showed catheter care orders but no order for catheter size or balloon inflation amount. For another resident with urinary retention, bowel incontinence, and an indwelling catheter, surveyors also found no order specifying Foley size or balloon amount, while staff gave inconsistent responses about how they determine those details.
Respiratory care was not provided in accordance with orders for two residents. One resident with OSA had a CPAP at the bedside, but the chart lacked orders for CPAP settings and routine cleaning/maintenance. Another resident with chronic respiratory disease was observed receiving O2 at 2.5 L via NC instead of the ordered 2 L, with no humidifier bottle attached despite an order for humidifier changes, and pulse ox checks were missed on scheduled dates.
A resident with ESRD, dialysis dependence, dementia, and severe cognitive impairment did not have consistent pre- and post-dialysis communication documented between the SNF and dialysis center. Staff could not locate current dialysis communication forms in the binder, the binder contained only old blank forms, and the resident’s record lacked documentation of routine monitoring for fistula complications such as bleeding. The DON and nursing staff gave differing descriptions of how dialysis communication was handled, and the care plan initially did not include access-site monitoring.
A resident with severe cognitive impairment was found with a bruise of unknown origin. Staff assessed the injury and notified the appropriate parties, but the NHA experienced technical issues that delayed the submission of the required five-day follow-up report to the State Agency. As a result, the final investigative findings were not reported within the mandated timeframe, violating reporting procedures.
A resident with severe cognitive impairment was found with a bruise on the forearm, and the facility's investigation was limited to interviews with the CNA who discovered the bruise and the RN who assessed it. The facility did not interview all staff who worked with the resident during prior shifts, as required by policy for injuries of unknown origin. This incomplete investigation led to a deficiency for not thoroughly addressing a potential abuse concern.
A resident with severe cognitive impairment and an activated HCPOA was not given the opportunity to participate in the development and implementation of their person-centered care plan. Despite multiple grievances and the facility's expectation to include activated HCPOAs in care conferences, there was no documentation that the HCPOA was invited or participated in two quarterly care conferences.
A facility did not thoroughly investigate an allegation of neglect involving a CNA and a resident, as only a portion of residents who may have had contact with the CNA were interviewed. Required reports were submitted, but the investigation did not include all potentially affected residents, and staff were unaware of the need to interview everyone involved.
Two residents with significant medical needs, including pressure injuries and dementia, repeatedly refused essential care and treatments such as wound assessments and use of heel boots. Despite documented refusals and staff awareness, the facility did not develop or implement care plans addressing these refusals, as confirmed by interviews with the DON and review of care records.
The facility failed to maintain sanitary conditions in its kitchens, with contaminated air vents, improperly stored food, and non-operational dishwashing equipment. Staff did not adhere to infection control practices, such as using hair restraints and proper hand hygiene, potentially affecting all 39 residents.
A resident's DNR status was not accurately reflected in the EHR for 19 days, despite being signed and filed in the paper chart. Staff relied on inconsistent sources to determine code status, leading to confusion. The discrepancy was discovered during a surveyor's review, revealing a gap in the facility's documentation procedures.
A resident with COPD, sleep apnea, and panic disorder continued to receive clonazepam beyond the original 14-day order due to a failure to transcribe an extended order into the physician orders and MAR. The extension was based on a pharmacy recommendation signed by an NP, but the transcription error was acknowledged by the DON during a surveyor interview.
A resident on a pureed diet reported tasteless food due to the Dining Room Manager not following a recipe, using water instead of chicken broth, and omitting thickener, resulting in a lack of nutritive value and improper consistency. The Food Service Director admitted to not providing printed recipes, despite having access to them.
The facility did not have a current contract for dialysis services for a resident receiving hemodialysis. The DON could not provide the contract, and the NHA confirmed its absence, acknowledging that it should exist. The resident receives dialysis three times a week, but no explanation was given for the missing contract.
Food Service Safety Lapses in Kitchen Sanitation, Food Handling, and Refrigeration
Penalty
Summary
Food service safety practices were not followed in the main kitchen and a satellite kitchen during survey observations. The Food Services Manager (FSM) was observed preparing and handling food without wearing a hair restraint to cover exposed facial hair, and the FSM stated there was an impression that no restraint was needed if facial hair was less than an inch long. The facility stated it followed the Wisconsin Food Code, which requires food employees to wear hair restraints designed to keep hair from contacting exposed food. During food preparation, a cook prepared puree recipes for cooked pork and cooked squash using the same blender blade. After the squash puree was completed, the blade was only rinsed in soap and water, and surveyors observed bits of squash still present on the blade before it was used for the pork puree. The FSM stated the blender blade should be run through the dishwashing machine between preparation of two foods. Surveyors also observed food debris on the main kitchen floor and underneath the stove and steamer over several days, and an opened jug of salsa dated 6/4/25 remained in the walk-in cooler with other ready-to-serve condiments. In the rehab satellite kitchen, the refrigerator was observed at 67 degrees Fahrenheit while containing milk, coffee creamer cups, pudding, Jello, grapes, and cut-up cantaloupe. The thermometer on the refrigerator showed the elevated temperature, there was no alarm or alert system, and the pudding, Jello, and coffee creamer cups were not cold to the touch. The cook who arrived later was unaware of the temperature issue and stated the refrigerator had been documented at 36 degrees Fahrenheit earlier that morning, but did not know how long it had been out of proper range. The FSM later stated the salsa would be discarded and that the refrigerator contents were discarded after the temperature concern was identified.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility did not ensure that residents transferred or discharged to the hospital, and their representatives when applicable, were provided written notice of the reason for transfer/discharge and the bed hold policy. Surveyors found that the facility’s notice of transfer and bed hold form did not include the Ombudsman’s email address, and the record review showed no evidence that the required written notices were provided for four residents reviewed for hospitalizations. R1 had multiple diagnoses including end stage renal disease, chronic respiratory failure with hypoxia, COPD, CHF, atrial fibrillation, dementia, and anxiety. R1’s POA for healthcare was activated, and a significant change MDS documented severe cognitive impairment with a BIMS score of 6. After a physician ordered transfer to the ER following an x-ray result, R1 left the facility for the hospital. The record showed the POA was notified, but there was no evidence that R1 or the POA received the reason for transfer/discharge and bed hold policy in writing. The notice of transfer and bed hold form in the chart included the Ombudsman’s phone number and address, but not the email address. Survey review also found that R1’s name was not on the September 2025 discharge list emailed to the Ombudsman. R2 was hospitalized twice, including one transfer for revision surgery to the right ankle and another for abnormal vitals and difficulty breathing. At the time of transfer, R2 was their own person. Surveyors reviewed the EHR and found no notice of transfer or bed hold notice provided in writing for the first hospitalization, and for the second hospitalization the electronic notice documented verbal consent only, with no evidence the information was conveyed in writing. R50, who had encephalopathy, severe protein-calorie malnutrition, vascular dementia with behavioral disturbance, and an activated POA, was hospitalized for poor intake, but no written notice of transfer or bed hold was located in the record. R3, who had moderate cognitive impairment, urinary retention, a urinary catheter, and an activated POAHC, was transferred to the hospital after becoming lethargic, febrile, and hyperglycemic; the POA agreed to the hospital transfer, but no bed hold and transfer notice was found in the medical record. Interviews with nursing, social work, admissions, and leadership showed staff described varying processes for completing and sending the forms, but no additional evidence was provided that the required written notices were given to these residents or their representatives.
Failure to Provide Adequate Supervision and Safety Devices to Prevent Resident Falls
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including dementia, hypertension, and anxiety, was assessed as having severe cognitive impairment and was dependent on staff for several activities of daily living. The resident had a history of falls and was identified as being at risk for further falls, with a care plan in place that included specific interventions such as the use of Dycem on the wheelchair cushion to prevent slipping. Despite these interventions being documented in the care plan and Kardex, observations on multiple occasions revealed that Dycem was not present on the resident's wheelchair cushion as required. Staff interviews confirmed a lack of awareness regarding the presence of Dycem, and direct observation by the surveyor on two separate days confirmed its absence. The resident was observed propelling herself in the wheelchair and participating in daily activities without the prescribed safety device in place. Additionally, after the resident experienced a fall, the facility did not conduct a thorough investigation. The incident report lacked staff statements, did not identify a root cause, and did not provide evidence that prior interventions were in place to prevent the fall. The investigation was incomplete, and there was no documentation explaining why the Dycem was not in use according to the care plan at the time of the fall.
Resident Left With Medications at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility did not ensure that 1 resident was clinically appropriate to self-administer medications. The resident had diagnoses including end stage renal disease, chronic respiratory failure with hypoxia, COPD, CHF, atrial fibrillation, dementia, and anxiety, and the significant change MDS documented a BIMS score of 6, indicating severe cognitive impairment. The facility policy required an interdisciplinary assessment of the resident’s cognitive, physical, and visual ability before allowing self-administration, along with a prescriber’s order, but the resident’s record did not contain an order to self-administer medications and the self-administration assessment in the chart was blank and marked in progress. During observation, the resident was seen with a white pill and approximately four pills in a medication cup on the breakfast tray on the overbed table next to the resident. When asked about the medication, the resident stated that nursing staff had just left them and that she took the big one first. A prior nursing note documented several medications found in the resident’s room that she did not take. Staff interviews indicated the resident did not self-administer medications, and the DON stated the resident could not self-administer her own medication, while also describing that the resident sometimes asked staff to leave the larger white pill so she could take it after eating.
Code Status Not Clearly Documented
Penalty
Summary
The facility did not ensure that 1 of 16 residents reviewed for advance directives had wishes clearly documented in the medical record. R2 was admitted with diagnoses including a displaced bimalleolar fracture of the right lower leg, chronic diastolic congestive heart failure, chronic kidney disease stage 3, and depression, and had an activated POA. Survey review found a signed State DNR form completed by R2's POA in the documents section of the EMR, but the top portion of the EMR did not list code status and the physician order section did not contain a current DNR order. During interview, RN-S stated a resident's code status should be identified by a bracelet, documentation in the medical record, and a physician order confirming the status. RN-S confirmed R2's EMR did not list code status under the resident's name and did not contain a physician order confirming DNR status. SW-N stated nursing staff asks the resident's preferred code status on admission, a facility and state form is completed and scanned into the EMR, and a physician order is obtained. DON-B also reviewed the record and confirmed the code status was not specified under R2's name and there was no current physician order stating R2 was DNR; DON-B found a discontinued DNR order that had been discontinued on 11/27/25 and stated not knowing why it was discontinued.
Failure to Provide Timely Pressure Injury Assessment, Staging, and Care Planning
Penalty
Summary
The facility did not ensure that two residents with pressure injuries, or at risk for pressure injuries, received necessary treatment and services consistent with professional standards of practice to prevent new pressure injuries and promote healing. R8 was assessed as high risk for pressure injury development, had severe cognitive impairment, was dependent for activities of daily living, bed mobility, and transfers, and had a history of incontinence and poor nutritional intake. R8’s care plan initially included general skin protection measures, but surveyor review noted no pressure injury prevention interventions addressing turning, repositioning, or heel offloading, and the care plan was not revised when heel boots and an air mattress were ordered or when the wound first appeared. R8 developed a wound to the right inner ankle/foot that was first described as a red intact fluid-filled blister and later progressed through multiple stages of worsening and healing. The wound was not always accurately staged, including documentation of a stage 2 pressure injury when the area had slough present and later back-staging of the wound from stage 3 to stage 2. The wound was also described at times with incomplete tissue documentation, and the care plan was not revised when the wound progressed, when slough was present, or when the wound worsened to stage 3. Surveyor review also noted that when R8 refused heel boots, there was no documentation that heels were floated on pillows as an alternative, despite an order allowing that option later in the course. R8’s wound eventually became infected, with documentation of redness, tenderness, pain with dressing changes, and antibiotic treatment for the right ankle wound. The report also states that R8 required two antibiotics to treat the infection and had pain at the wound. Surveyor interview with the wound RN confirmed that a wound with slough should be staged as stage 3 and that heel boots are typically used for residents at risk for pressure injury, but the RN was not sure why the wound worsened or why the care plan had not been updated earlier. In addition, R21 developed a pressure wound to the right gluteus, but it was not comprehensively assessed by an RN until 10 days later, and R21’s care plan was not revised to include interventions related to the new pressure wound.
Foley Catheter Care and Order Details Not Properly Maintained
Penalty
Summary
The facility did not ensure appropriate catheter care and urinary catheter orders for 2 residents with indwelling Foley catheters. For one resident, who was admitted with diagnoses including bladder cancer, obstructive sleep apnea, and diabetes mellitus, surveyors observed the Foley catheter bag directly on the floor without a protective cover or barrier during multiple observations in the resident’s room. An LPN interviewed about the observation stated that Foley catheter bags should always be covered and kept off the floor. Record review for that resident showed a physician order for catheter care every shift, but no physician order specifying the proper catheter size or balloon inflation amount. Surveyors raised this concern with the NHA and DON, and no additional information was provided at that time. The resident’s MDS admission assessment and comprehensive care plan had not yet been completed. For the second resident, who had a history of urinary tract infections, urinary retention, and urogenital implants, the MDS documented moderate cognitive impairment, dependence for all cares, bowel incontinence, and a urinary catheter. The care plan and physician orders included catheter care, monitoring output, irrigation PRN, and drainage bag changes, but surveyors noted there was no order stating the Foley size or balloon inflation amount. Multiple nurses stated they would look to physician orders for that information, while others said they would rely on the current catheter or hospital orders; the DON and regional nurse consultant stated they had never seen an order listing catheter size and balloon amount and had personally used the existing catheter for reference.
Respiratory Care Orders Not Followed
Penalty
Summary
Safe and appropriate respiratory care was not provided for 2 residents. One resident with obstructive sleep apnea had a CPAP machine at the bedside, and the record showed only an order to assist with placement and function at bedtime. Survey review did not identify physician orders for the CPAP settings or for cleaning and maintenance of the device. Nursing staff stated that CPAP settings should be entered into the medical record and that there should be routine cleaning orders, but those orders were not found in the resident’s record. Another resident with chronic respiratory failure with hypoxia, COPD, CHF, dementia, and anxiety had physician orders for oxygen at 2 liters via nasal cannula and for a humidifier canister to be changed every Friday night shift. Survey observations repeatedly found the resident receiving oxygen at 2.5 liters via nasal cannula, not 2 liters, and no humidifier bottle attached to the concentrator. The humidifier bottle was later found sitting on furniture in the resident’s bathroom rather than on the oxygen concentrator. Record review also showed the resident’s pulse oximetry was not checked on two scheduled dates per physician order. When questioned, an RN was unsure whether the resident should have a humidifier bottle and then confirmed the order after reviewing the chart. The DON stated the resident was independent with oxygen and that routine monitoring was not done every four hours, while also acknowledging the oxygen setting observed by the surveyor differed from the ordered amount.
Dialysis Communication and Access Monitoring Not Consistently Documented
Penalty
Summary
The facility did not ensure consistent pre- and post-dialysis communication and monitoring for complications for a resident receiving hemodialysis. The resident had end stage renal disease, dependence on renal dialysis, dementia, and anxiety, and a significant change MDS showed a BIMS score of 6, indicating severe cognitive impairment. The facility policy stated that care for an individual receiving dialysis would be coordinated and communicated between the SNF and the dialysis staff, with the resident record reflecting exchange of pertinent information before, during, and after dialysis, including emergency contact information. The resident’s dialysis care plan included interventions such as not drawing blood or taking blood pressure in the arm with the graft, encouraging attendance at scheduled dialysis, monitoring dry skin, monitoring labs, and monitoring and reporting signs and symptoms of renal insufficiency and peripheral edema. However, the care plan did not include an intervention to monitor the access site for complications such as bleeding. The resident’s physician orders included sending a dialysis binder and a bag lunch with the resident on dialysis days, and the TAR showed the binder order was checked as completed on dialysis days. When the surveyor asked staff where the binder was kept, staff were unsure, and the binder provided contained only two communication sheets from 2024, with no 2025 forms present. The surveyor reviewed the binder and found blank communication forms intended for the nursing facility to complete before dialysis and for the dialysis unit to complete after treatment, but the forms in the binder were not completed by the facility. Staff stated they did not call the dialysis center every Monday, Wednesday, and Friday, and the DON initially stated the binder was used for communication and that monitoring for fistula complications would be in the TAR, but the TAR did not contain such monitoring. The DON later stated the facility communicated by email and phone and provided some printed notes, including dietitian communications and dialysis center notes, but the surveyor still could not locate consistent communication between the facility and dialysis center for the resident or documentation of monitoring for fistula complications such as bleeding in the resident’s record.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for a resident who was severely cognitively impaired. The resident was found with a new bruise on the left forearm, which was first noticed by a CNA. The resident was unable to clearly recall how the bruise occurred, providing inconsistent explanations, and staff interviews did not reveal any clear cause. The CNA who discovered the bruise promptly notified a nurse, and the incident was assessed and documented, with the resident’s Power of Attorney and physician being notified. According to facility policy, any incident or allegation considered reportable must be initially reported to the State Agency immediately or within 24 hours, with a follow-up investigation submitted within five working days. In this case, the Nursing Home Administrator (NHA) was made aware of the bruise and conducted interviews with the resident and staff, as well as a review of the resident’s environment. The NHA determined that no abuse had occurred and that the injury was likely accidental, possibly related to a malfunctioning dresser drawer or contact with a transfer device. However, the NHA encountered technical difficulties with the reporting system, including an expired account and issues submitting the required documentation. Despite attempts to notify the State Agency via email and eventually submitting the final investigation report, the required five-day follow-up report was not submitted within the mandated timeframe. The NHA acknowledged the delay and was unable to provide evidence of timely submission. The surveyor confirmed that the final investigative findings were not reported to the State Agency within the required five working days, constituting a deficiency in the facility’s abuse, neglect, and incident reporting procedures.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of an injury of unknown origin for one resident. A bruise was discovered on the resident's left forearm, and initial interviews were conducted with the Certified Nursing Assistant (CNA) who found the bruise and the Registered Nurse (RN) who assessed it. The resident, who is severely cognitively impaired, provided inconsistent accounts of how the bruise occurred, at times referencing bumping into a transfer device or a dresser drawer, but was unable to recall specific details. The facility's investigation included interviews with the resident, CNA, and RN, as well as interviews with other residents on the unit. However, the facility did not interview or obtain statements from all staff members who had worked with the resident during the shifts prior to the discovery of the bruise. Staff schedules indicated that additional CNAs were present during the relevant timeframe, but their input was not sought as part of the investigation. The facility's self-report and documentation did not reflect a review of staff schedules or comprehensive staff interviews to determine if any staff had observed the bruise earlier, witnessed the incident, or had information about transfers involving the resident. The facility's policy requires that all injuries of unknown origin be immediately and thoroughly investigated to rule out abuse. Despite this, the investigation was limited in scope and did not include all potentially relevant staff. The deficiency was identified when the surveyor noted the lack of comprehensive staff interviews and the absence of a full review of staff schedules in the facility's investigative process.
Failure to Involve Activated HCPOA in Care Planning
Penalty
Summary
A resident with diagnoses of dementia with anxiety, mood disturbance, and edema was admitted to the facility and had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment and inability to make daily decisions. The resident had an activated Healthcare Power of Attorney (HCPOA) responsible for participating in care planning. Despite this, the facility did not formally invite the HCPOA to participate in the resident's quarterly care conferences, as confirmed by both grievance logs and interviews with the HCPOA. Documentation for care conferences on two separate dates showed no evidence that the HCPOA was invited or participated. The surveyor reviewed multiple grievances from the HCPOA regarding lack of notification and participation in care conferences. Interviews with facility staff confirmed that the expectation was to include activated HCPOAs in quarterly care conferences, but this was not done for the resident in question. The administrator and DON were made aware of the concern, and no additional information was provided to indicate that the HCPOA was given the opportunity to be involved in the resident's care planning process.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted into an allegation of neglect involving a resident and a Certified Nursing Assistant (CNA). A self-report was submitted to the State Agency documenting allegations that a resident was neglected by the CNA. While the facility submitted the required reports to the State Agency within the appropriate timeframes, the internal investigation did not include interviews with all residents who may have had contact with the CNA on the South unit. The investigation was limited to interviews with only 12 out of 16 residents on the unit, and there was no documentation showing attempts to interview the remaining residents. The staff member responsible for the investigation stated they were unaware that all potentially affected residents should have been interviewed, believing that only a sample was necessary. The facility was unable to provide additional information or documentation to demonstrate that a comprehensive investigation had been completed.
Failure to Develop Care Plans for Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing refusal of care for two residents. One resident, admitted with a history of myocardial infarction and a sacral pressure injury, repeatedly refused evaluation and repositioning for a hospital-acquired coccyx pressure injury. Progress notes documented these refusals and the resident was educated on the risks and benefits, eventually agreeing to reposition every four hours. Despite these ongoing refusals and the resident's history of declining care, no care plan addressing refusal of care was developed during the resident's stay. Interviews with facility staff, including the wound nurse and DON, confirmed that a care plan for refusal of care should have been in place but was not. Another resident, admitted with dementia and chronic pain, had physician orders for heel boots to prevent pressure injuries. This resident was observed without heel boots on multiple occasions and had a documented stage 2 pressure injury. The resident frequently refused to wear the heel boots, as noted by both staff interviews and the treatment administration record, which showed at least 12 refusals over a period of several months. Despite this pattern of refusal, the resident's care plan did not address refusal of care. The DON confirmed that a care plan for refusal of care was required but had not been developed for this resident.
Sanitation and Infection Control Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner, affecting all three kitchens and potentially impacting all 39 residents. In the main preparation kitchen, air vents over the sink and near the dishwasher were found to be contaminated with dark brown spots, and the cleaning schedule was not adhered to, with the last cleaning occurring over seven months prior. Additionally, food items in the refrigerators were not properly dated or sealed, leaving them open to contamination, contrary to the facility's policy. In the Rehab/West Unit, the commercial dishwashing machine was non-operational, leading staff to use a residential dishwashing machine without proper sanitization or temperature logs. This practice was against the facility's guidelines, which required dishes to be washed in the main or Long Term Care kitchen. The lack of an approved dishwashing machine and the improper use of a residential machine posed a risk of inadequate sanitization of dishware. In the Long Term Care Unit kitchen, staff failed to follow infection control practices. Dietary staff handled clean dishware without gloves or proper hand hygiene, and a CNA was observed in the kitchen without a hair restraint, despite facility policy requiring hairnets. These lapses in infection control practices were observed and reported to the Nursing Home Administrator, who acknowledged the issues but did not provide further information.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's resuscitation code status was accurately reflected in their electronic health record (EHR) for the first 19 days of their stay. The resident, who was cognitively intact and had signed a Do Not Resuscitate (DNR) order on admission, was incorrectly documented as a full code in the EHR. This discrepancy was not identified until a surveyor's investigation revealed that the resident's DNR status was not transcribed into the EHR, despite being signed and filed in the paper chart. Staff interviews indicated a lack of clarity and consistency in the process for documenting code status. Certified Nursing Assistants and Licensed Practical Nurses relied on different sources, such as bracelets and Medication Administration Records, to determine code status, leading to confusion. The Director of Nursing acknowledged the discrepancy but could not explain why the signed DNR form was not scanned into the EHR. The issue was only discovered during a surveyor's review, highlighting a gap in the facility's procedures for ensuring accurate documentation of residents' code status.
Failure to Transcribe Physician Orders Correctly
Penalty
Summary
The facility failed to ensure that a resident's physician orders were transcribed correctly, resulting in a deficiency. A resident, identified as R24, was admitted with diagnoses including COPD, sleep apnea, and panic disorder. The resident had a physician order dated February 5, 2024, for clonazepam 0.5 mg to be administered twice daily as needed for anxiety, limited to 14 days. However, by July 23, 2024, the resident continued to receive this medication despite the original order's expiration. During an interview, the Director of Nursing (DON) acknowledged that the order was extended for another six months based on a pharmacy recommendation signed by a nurse practitioner on March 8, 2024, but this extension was not transcribed into the physician orders or the medication administration record (MAR). The facility did not provide additional information on why the transcription error occurred.
Failure to Follow Recipe for Pureed Diet
Penalty
Summary
The facility failed to ensure that food was prepared to conserve nutritive value and flavor for a resident on a pureed diet. The Dining Room Manager (DM-D) did not follow a recipe when preparing pureed food, instead relying on personal experience to determine the correct texture and consistency. During the preparation of a pureed chicken dish, DM-D used an unmeasured amount of hot water instead of chicken broth, which did not conserve the nutritive value of the food. Additionally, DM-D did not use thickener, resulting in a mixture that was not of a smooth, pudding-like consistency as required. The resident, who is cognitively intact and has diagnoses including chronic heart failure, protein-calorie malnutrition, and colon cancer, reported that the food lacked flavor. The Food Service Director (FSD-C) acknowledged the absence of printed recipes for pureed food, despite having access to a computer program with the necessary recipes. The Dietician (D-H) confirmed that recipes should be used for residents on pureed diets and provided the correct recipe for pureed baked chicken breast, which included specific measurements for chicken broth and thickener. The deficiency was communicated to the Nursing Home Administrator and Director of Nursing during the daily exit meeting.
Lack of Dialysis Service Contract
Penalty
Summary
The facility failed to secure a current contract or agreement for outside dialysis services for a resident receiving hemodialysis. During a survey, the Director of Nursing (DON) was unable to provide a dialysis contract for the company used by the resident, identified as R19, who receives dialysis three times a week. The Nursing Home Administrator (NHA) confirmed the absence of a contract and acknowledged that one should be in place. Despite requests for additional information, no explanation was provided for the lack of a dialysis contract for the resident's provider.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mukwonago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Troy Manor | 4.3 mi | ★★★★★ | 5 | 0 |
| Masonic Center For Health & Rehab Inc. | 11.6 mi | ★★★★★ | 1 | 0 |
| Lakeland Health Care Ctr | 13 mi | ★★★★★ | 7 | 1 |
| Holton Manor | 13.2 mi | ★★★★★ | 19 | 0 |
| Complete Care At Kensington | 13.6 mi | ★★★★★ | 5 | 0 |
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