Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Muskego Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident developed a facility-acquired unstageable heel pressure injury after the care plan did not address the resident’s shoe-wearing preference or include timely offloading interventions, and the wound worsened with repeated gaps between wound orders and the care plan. Two other residents also had pressure injury care failures, including missing ordered heel offloading and delayed wound assessment. Surveyors noted delayed assessments, incomplete documentation, and wound care plans that did not match physician/NP orders.
Annual performance reviews were not completed for 5 of 5 CNAs reviewed, including CNA-E, CNA-G, CNA-H, CNA-I, and CNA-J. The surveyor reviewed records, requested the missing evaluations, and the NHA confirmed the reviews were not completed within the required 12-month period; all five CNAs had contact with residents throughout the facility.
Drugs in 1 of 2 med carts were not labeled in accordance with accepted professional principles. Surveyors found expired stock meds and loose pills scattered in the cart drawers, and RN-N stated the loose pills and expired meds should go into the drug buster. RN-N did not recall being trained or assigned to clean the carts, and the DON said pharmacy only reviews and cleans the carts quarterly.
Failure to maintain resident dignity during mealtime assistance: A DON and CNAs were observed standing over two dependent residents while feeding them in the dining room, and the staff did not converse with the residents during the meals. One resident had severe dementia and was dependent for eating, and the other had vascular dementia, CVA-related deficits, swallowing difficulty, and required assistance with all meals. The facility policy stated staff should focus on the resident, talk to the resident individually, and be seated if possible while feeding.
Unassessed Right Knee Wound Without Treatment Order: A resident with multiple sclerosis, contractures, urinary retention, and impaired mobility had a border gauze dressing observed on the right knee, but there was no wound assessment or treatment order in the chart. RN staff confirmed the dressing was in place without an order, and the NP later documented the area as a partial-thickness abrasion/shear covered with xeroform and border gauze.
A resident with hearing loss did not receive proper follow-up for an audiology consult after the exam could not be completed because of heavy cerumen in both ears. The resident reported decreased hearing and said the wax had been removed, but the chart lacked documentation of a hearing care plan or completed audiology follow-up. Interviews with SW, MR, MDS staff, CNA, and the NHA confirmed the resident remained hard of hearing and that the facility had no documentation of the needed follow-up.
A resident with hemiplegia, depression, and anxiety had cracked crowns, missing teeth, jaw pain, and difficulty chewing, but a dental referral was not followed through for months. The resident reported ongoing pain when eating and said staff had been told repeatedly about the issue, while the MDS and nutrition assessments did not reflect the dental concern. Staff interviews showed the SW, MDS nurse, CNA, and MR/receptionist were not aligned on follow-up, and the NHA acknowledged there was no documentation explaining the delay.
A resident with osteomyelitis, diabetic foot ulcers, Parkinson’s disease, and moderate cognitive impairment, care planned as at risk for falls due to weakness, NWB LLE, and forgetfulness, experienced multiple falls. EMR review showed that for two of four falls, IDT fall notes documented the circumstances (rolling from bed while repositioning and being found squatting in the bathroom while attempting to get on the toilet) and that assessments, neuro checks, and VS were WNL with no injuries, but did not document whether the resident was asked about or consented to family notification, nor that family was notified. The DON confirmed that the resident was his own decision-maker, that family was notified or present for two of the falls, and that there was no documentation of the resident’s wishes or family notification for the other two falls, contrary to the facility’s “Notification of Changes” policy requiring notification of a resident representative for significant health status changes, including accidents.
The facility failed to maintain complete and accurate EMR documentation for three residents, including one with diabetic foot wounds and Parkinson’s disease, one with a brain injury and severe cognitive impairment, and one with multiple sclerosis. Missing entries included weekly skin assessments, weekly weights, meal intake percentages, and incontinent care on numerous dates, and in some cases incontinent care was recorded only once per day despite residents being always incontinent of bowel and bladder. A CNA reported that agency CNAs often did not complete documentation, and the Administrator and DON acknowledged missing documentation, contrary to the facility’s policy requiring timely and accurate charting each shift.
A resident with multiple chronic conditions reported that an LPN entered her room without knocking and attempted to administer medication while she was on the toilet, causing her distress. The incident was disclosed to a CNA and later to a social worker, but the facility did not report the abuse allegation to the state agency within the required two-hour timeframe, as confirmed by interviews and record review.
A resident with a stage 4 pressure ulcer did not receive wound care in accordance with current provider orders, as an LPN used an outdated solution and failed to perform hand hygiene at multiple required steps during a dressing change. Interviews confirmed that the care provided did not follow the most recent orders or facility policy.
A resident with multiple chronic conditions did not receive several prescribed medications, including those for blood pressure, thyroid function, pain, GERD, and potassium supplementation, on at least five occasions over two months. MARs showed missed doses, and both an LPN and the administrator confirmed these omissions as medication errors, despite facility policy requiring accurate administration and documentation.
A resident with a stage 4 pressure ulcer received wound care from an LPN who failed to wear a gown as required by the facility's Enhanced Barrier Precautions policy. The LPN performed the dressing change using only gloves, despite signage and policy indicating that both gloves and a gown were necessary for high-contact activities like wound care. The deficiency was confirmed through observation and staff interviews.
A resident filed a grievance about a CNA's conduct, and although the facility documented that the CNA would no longer be assigned to that resident, records show the CNA continued to provide care on several occasions. The scheduler was not informed of the restriction, and the CNA confirmed ongoing involvement in the resident's care, indicating a failure to follow through on the grievance resolution.
A resident with moderate cognitive impairment and significant physical limitations did not receive weekly showers as required by facility policy and their care plan. Despite being scheduled for weekly showers and expressing a preference for them, the resident received only one shower in a 30-day period, with no refusals documented. Both the NHA and DON confirmed that weekly showers should have been provided.
A resident with quadriplegia and existing heel pressure injuries did not consistently receive physician-ordered bilateral heel protectors, as documentation showed they were only applied during two specific periods and not at all other required times, according to the DON and record review.
The facility's daily nursing staff postings for the SNF were found to be inaccurate, with CBRF hours included and incorrect numbers of CNAs listed for night shifts. The postings did not match actual staff assignments, and written records of daily assignments were not maintained, leading to multiple days of inaccurate documentation.
The facility did not maintain an effective system to verify that nurses held valid licenses, allowing an LPN with a revoked license to work. Allegations of verbal abuse and misappropriation of property involving residents were not reported or investigated according to policy, with delays and omissions in notifying the NHA and State Survey Agency. These failures resulted in noncompliance with required abuse prevention and reporting procedures.
Surveyors found that the facility did not consistently implement infection prevention and control measures, including missing or improperly placed enhanced barrier precaution signage, and staff failing to use appropriate PPE and perform hand hygiene during care for residents with wounds or medical devices. Staff were sometimes unaware of which residents required EBP, and lapses in infection control practices were observed during wound care, incontinence care, and G-tube flushing.
A resident with multiple medical conditions and a legal guardian was transferred between rooms without prior written notice or consent from the resident or guardian. Staff interviews confirmed that required documentation and consent for the room changes were not completed, in violation of facility policy.
A resident with multiple complex conditions experienced significant weight loss, possible thrush, and missed prescribed tube feedings due to formula unavailability. Despite facility policy requiring prompt physician notification for such changes, there was no documentation that the physician was consulted about the weight loss or thrush, and communication gaps between the RD, nursing staff, and physician were identified.
A resident with severe cognitive impairment and total care needs was subjected to verbal abuse by a CNA, while staff failed to report previous similar incidents involving the same CNA. Despite clear signs of distress and a request for a different caregiver, the accused CNA continued to provide care, and facility leadership did not immediately recognize or act on the abuse allegation, delaying the investigation and failing to protect the resident as required by policy.
The facility did not promptly report multiple allegations of abuse and misappropriation involving three residents to the NHA and State Survey Agency as required. In one case, staff overheard a CNA verbally abusing a resident but failed to report it immediately. In another, a resident reported missing money, but the incident was not reported until days later. A third resident reported being yelled at by a nurse, but the allegation was not timely communicated to the NHA or reported to authorities. These delays violated facility policy and regulatory requirements for immediate reporting.
Three residents with varying degrees of cognitive and physical impairment experienced alleged verbal abuse by staff, but the facility failed to promptly or thoroughly investigate these allegations as required by policy. In each case, staff either did not report the incidents or delayed initiating investigations, and in one instance, the accused CNA continued working the entire shift after the allegation was known. The facility did not ensure timely protection or follow-up for the affected residents.
Two residents with complex wounds did not receive timely or appropriate wound care as ordered by physicians, including missed or delayed assessments, incomplete or improperly performed treatments, and lack of documentation. Staff failed to follow established protocols for wound assessment and treatment initiation, resulting in missed care and deviations from professional standards.
A resident with multiple pressure injuries did not receive timely and appropriate wound care as ordered by the wound physician, including delays in implementing new treatment orders, discontinuation of prescribed treatments, and failures in pressure injury prevention such as improper use of pressure-relieving devices and incorrect air mattress settings. Staff interviews revealed confusion about responsibilities for reviewing and updating wound care orders, leading to lapses in care.
A resident with a history of falls, cognitive impairment, and NPO status experienced multiple unwitnessed falls, was mistakenly given oral food despite PEG tube orders, and attempted to elope. The facility did not conduct thorough investigations, failed to identify patterns, and did not implement timely, person-centered interventions or care plan updates following these incidents.
A resident with multiple complex medical conditions experienced significant weight loss after missing several prescribed tube feedings due to unavailable formula. Staff failed to notify the physician of the weight loss, did not consistently obtain required weights, and did not update the care plan or implement new interventions in response to the resident's declining nutritional status. Recommendations from the registered dietitian and a swallow study were not fully communicated or acted upon.
A resident with end stage renal disease who receives dialysis three times a week did not have consistent pre- and post-dialysis communication between the facility and the dialysis center. Review of records showed only one incomplete dialysis communication form during a period when multiple treatments occurred, and staff interviews revealed inconsistent processes for sending and receiving these forms, with no follow-up when documentation was missing.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. EBP signs were not consistently posted, and staff were unaware of which residents required precautions. Additionally, the infection surveillance system was inadequate, with no monthly infection rates calculated or reported to the QAPI committee. This resulted in multiple residents not receiving necessary precautions to prevent infection transmission.
The facility failed to ensure residents were free from accident hazards and received adequate supervision, as several falls were not thoroughly investigated, and care plans were not promptly updated. Additionally, a resident assessed as needing supervision while smoking did not have a smoking care plan, and smoking materials were improperly stored. The investigation process for falls was inadequate, with missing staff statements and incomplete documentation.
A resident with limited English proficiency was not provided with adequate communication resources in their primary language, Serbian, at a facility. The facility relied on family members for translation, contrary to its policy, and failed to include proper communication methods in the resident's care plan. Staff were unaware of available translation resources, leading to the resident not being fully informed about their health status and care.
The facility failed to provide written transfer/discharge notices to two residents when they were hospitalized. Despite having a policy in place, the facility did not ensure that the residents or their representatives received written notices including the date, reason, and location of transfer, as well as appeal rights and contact information for the State LTC Ombudsman. Staff interviews revealed a reliance on verbal notifications, and the DON acknowledged that written notices were not provided but would be in the future.
A resident with multiple diagnoses and at risk for pressure injuries did not receive consistent treatment for a lower back pressure ulcer, which increased in size over 14 weeks. The facility's records showed gaps in wound care, and there was no documentation of skin discolorations on the resident's heels and feet. The DON acknowledged the missing treatments and lack of documentation, focusing on larger ulcers causing pain while other areas were monitored.
A resident with hemiplegia following a stroke did not receive appropriate contracture management due to a lack of communication and documentation. The resident was observed without the prescribed splint or palm guard, and the care plan was not updated to reflect changes made by OT. Staff interviews revealed a lack of awareness about the resident's current treatment plan.
A resident admitted with a colostomy did not receive timely care consistent with professional standards. The facility failed to obtain physician orders for colostomy care until 10 weeks after admission, resulting in a lack of consistent documentation of necessary care. Interviews with staff confirmed the expectation for physician orders, which were not met, and the resident expressed concerns about the care received.
A resident requiring dialysis care did not have physician orders or a care plan in place, and assessments before and after dialysis sessions were not documented. The facility failed to ensure ongoing communication with the dialysis center, as only one partially completed communication form was provided despite multiple dialysis sessions. This lack of documentation and communication was inconsistent with professional standards of practice.
A resident requiring a sit-to-stand mechanical lift for transfers was assisted by a Resident Assistant (RA) not certified as a CNA, who performed pivot transfers instead. The RA, employed on the CBRF side, was not authorized to assist LTC residents, leading to a deficiency in staff competency and adherence to the care plan.
A resident with HIV disease missed five doses of Epoetin Alfa Injection due to the facility's failure to ensure medication availability and proper communication with the physician and pharmacy. Despite having a protocol to address such issues, the facility lacked a specific policy on missed doses, leading to the deficiency.
A facility failed to act on pharmacy medication review recommendations for a resident with multiple diagnoses, including dementia and epilepsy. The recommendations, which included medication adjustments to comply with CMS guidelines, were not reviewed or acted upon by the physician until prompted by a surveyor. The facility's process for handling pharmacy recommendations was not followed, leading to a delay in addressing the resident's medication regimen.
The facility failed to monitor adverse reactions for high-risk medications in two residents prescribed anticoagulants and diuretics. Despite facility policy, no care plans were implemented for monitoring potential side effects. The DON confirmed the absence of necessary care plans, highlighting a lapse in adherence to medication management guidelines.
A facility failed to monitor adverse effects and implement non-pharmacological interventions for a resident on psychotropic medications, and did not document an end date for another resident's PRN Lorazepam order. The first resident, with severe depression, lacked behavior monitoring, while the second resident's PRN order violated the facility's policy requiring a 14-day limit without documented rationale. These deficiencies highlight non-compliance with the facility's medication policies.
Two residents who consented to receive influenza and pneumococcal vaccines did not receive them due to lapses in the facility's immunization process. The DON acknowledged the oversight, noting the need to check vaccine stock and order from the pharmacy, but no orders were found in the medical records.
A facility failed to report an allegation of neglect involving a resident with vascular dementia and other conditions. The resident's family reported that the resident was left wet and unattended, and staff were unresponsive and rude. The Nursing Home Administrator did not report these allegations to the State Survey Agency, as required by policy.
The facility failed to thoroughly investigate a resident-to-resident altercation and an allegation of neglect. In the first case, two residents were involved in an altercation, but the investigation lacked comprehensive interviews and verification of events. In the second case, a resident's family reported neglect, but the investigation was incomplete, lacking staff statements and documentation of care. The facility's policies require thorough investigations, which were not conducted in these instances.
The facility did not ensure sufficient nursing staff by failing to designate a charge nurse for each shift, as revealed by a surveyor's review of nursing schedules and staff postings. The Director of Nursing was unaware of this oversight, which potentially affected all 39 residents.
The facility did not include the daily resident census in its nurse staff postings, as required. This was discovered during a survey when the surveyor reviewed nursing schedules and postings due to concerns about low weekend staffing. The DON acknowledged the omission and indicated plans to include the information in future postings. The NHA was informed, but no further information was provided by the facility.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds, catheters, or gastrostomy tubes, as rooms lacked necessary signage and physician orders for EBP were missing. Additionally, a CNA did not change gloves between cleaning a resident's perineal area and applying a clean incontinence brief, violating infection control practices. These deficiencies were confirmed by staff and administration, increasing the risk of cross-contamination.
The facility failed to ensure proper transcription and administration of physician orders for wound care and antibiotics. A resident with malnutrition and quadriplegia did not receive necessary dressing changes due to missing orders in the EMR. Another resident did not receive prescribed antibiotics for pneumonia due to a transcription error. The DON confirmed systemic issues in the transcription process, leading to potential harm from lack of treatment.
Failure to Provide Timely Pressure Injury Care and Offloading
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for three residents with pressure injuries. One resident was admitted at high risk for pressure injuries and later developed a facility-acquired unstageable left heel pressure injury. The resident’s care plan did not include a pressure-relieving boot for the left foot until months after the wound was identified, and the care plan did not address the resident’s preference to wear shoes. The record also did not document that the resident or responsible party was informed of the risks and benefits of not removing the shoes, which the DON identified as the root cause of the heel injury. The care plan also did not document interventions to address the resident’s refusal to remove shoes. A second resident was observed without the ordered treatment in place for a healed right hip pressure injury and without heel offloading while in bed, despite physician orders for heel protection. The resident’s stage 1 right ischial tuberosity pressure injury was observed open, but the wound was not assessed until two days later. For the third resident, admitted with a stage 4 sacral pressure ulcer, the pressure ulcer was not assessed with measurements and description until several days after admission. The facility policy required full body skin assessments, wound measurements, and prompt assessment and treatment, including care plans with interventions based on risk factors and wound characteristics. For the resident with the left heel wound, the wound was first identified as unstageable and later worsened over time with increasing size, maceration, necrotic tissue, drainage, tunneling, undermining, and odor. Surveyors noted repeated gaps between wound treatment orders and the care plan, including failure to add ordered offloading interventions such as a Prevalon boot and offloading mattress, and failure to individualize repositioning. The resident’s nutritional support was also not updated when the wound developed, despite the wound orders repeatedly emphasizing protein supplementation. The wound assessments were often completed by LPNs, with blank RN review comments, and the wound was not consistently reassessed by an NP during the period described.
Annual CNA Performance Reviews Not Completed
Penalty
Summary
The facility did not ensure that annual performance reviews were completed every twelve months for 5 of 5 Certified Nursing Assistants reviewed: CNA-E, CNA-G, CNA-H, CNA-I, and CNA-J. The facility policy stated that employee competency is evaluated through the training program and that subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. It also stated that additional training is provided based on areas of weakness identified in performance reviews. On 7/6/26, the surveyor reviewed the annual performance reviews for the five randomly selected CNAs and requested their records from the Administrator. On 7/7/26, the surveyor noted that none of the five CNAs had had an annual performance review completed in the last twelve months. On 7/8/26, the NHA stated that completed annual performance reviews could not be located for CNA-E, CNA-G, CNA-H, CNA-I, and CNA-J, and said that CNA-E and CNA-G's reviews were completed that morning while the reviews for CNA-H, CNA-I, and CNA-J would be completed soon. The NHA confirmed that all five CNAs had contact with residents throughout the facility.
Expired and Loose Medications Found in Medication Cart
Penalty
Summary
Drugs used in the facility were not labeled in accordance with currently accepted professional principles for 1 of 2 medication carts observed. Surveyors observed the side 2 medication cart with RN-N and found two stock over-the-counter medications, Calcium vitamin D and Complete Multivitamin Adult 50+, with manufacturer expiration dates of 06/2026, along with 35 loose pills scattered throughout the cart drawers. RN-N stated that loose pills and the expired stock medications should be placed in the drug buster in the medication room and said all nurses are responsible for cleaning medication carts, but did not recall being trained on or assigned that task. DON-B stated that pharmacy comes quarterly to review and clean out medication carts and the medication room, and that the facility did not currently have a process for cleaning out medication carts to remove expired medications outside of the quarterly pharmacy visits. Surveyors also noted 6 expired stock medications and 63 loose medications in the medication carts.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility did not ensure that residents were treated with dignity and respect during mealtime. During lunch in the dining room, the DON and a CNA were observed standing over R22 while assisting with feeding, and the CNA did not engage in conversation with R22. The facility policy on promoting and maintaining resident dignity during mealtimes stated that staff should treat each resident with respect and dignity, focus on the resident while talking to him or her individually, and be seated if possible while feeding a resident. R22 was admitted with diagnoses including other specified intracranial injury and unspecified severe dementia with anxiety. The resident’s MDS documented impaired short- and long-term memory, severely impaired decision-making skills, and dependence for eating. Care plans identified R22 as needing assistance with eating and being dependent for eating, and also noted swallowing difficulty, altered texture diet needs, and the need for set up and assistance with all intake. On 7/6/2026, the surveyor observed the DON standing over R22 while encouraging the resident to eat and drink, then observed CNA-F standing over R22 while feeding the resident without conversing. R24 was admitted with diagnoses of hemiplegia and hemiparesis following CVA affecting the right side and vascular dementia. The resident’s MDS documented impaired short- and long-term memory, severely impaired decision-making skills, and dependence on staff for eating. Care plans and the nutritional evaluation documented that R24 required assistance with all meals and had swallowing difficulty, variable PO intake, and a history of pocketing and holding boluses. On 7/6/2026, the surveyor observed CNA-E assisting R24 by standing over the resident while feeding, holding the resident’s plate, and not conversing during the meal. CNA-E later stated that the proper way to feed residents was to be sitting while assisting them, and the NHA confirmed that standing over residents while feeding was not the facility’s policy and was not dignified.
Unassessed Right Knee Wound Without Treatment Order
Penalty
Summary
The facility did not ensure that R15 received necessary care and treatment based on assessment and provider orders when a border gauze dressing was observed on R15’s right knee without any corresponding wound assessment or treatment order. R15 was admitted with diagnoses including multiple sclerosis, contractures, urinary retention, need for assistance with personal care, and a non-pressure chronic ulcer of the skin. The annual MDS indicated intact cognition, dependence for rolling left to right, impairment of both upper and lower extremities, risk for pressure injuries, and an indwelling urinary catheter. Surveyor observation on 07/06/2026 found a dressing in place on the right knee during care, but review of physician orders showed no treatment order for that area. Wound notes and weekly skin checks contained no assessment of the right knee wound, and the last skin assessment documented intact skin. RN-O stated the right knee was covered with a foam border dressing but there was no order in the electronic health record. Later that day, NP-P documented the right knee as a partial thickness abrasion/shear measuring 1.0 cm x 1.5 cm x 0.1 cm, pink with no drainage and normal periwound, and noted it was covered with xeroform gauze and border gauze. DON-B stated that new open wounds should be reported to the provider and DON to ensure proper and timely assessment.
Failure to Follow Up on Audiology Evaluation for Resident With Hearing Loss
Penalty
Summary
The facility did not ensure a resident with hearing impairment received proper treatment and assistive services, including follow-up for an audiology evaluation. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, depression, major depressive disorder, and anxiety disorder. The resident’s quarterly MDS dated 5/18/26 indicated a BIMS score of 14 and documented no hearing concerns, but the resident later told the surveyor that hearing had decreased and that a hearing test had been planned but could not be completed because of extreme wax buildup in both ears. Record review showed an audiology referral was made on 10/22/25 due to decreased hearing, and the audiology exam on 10/25/25 could not be completed because wax was so deep in both ears that it needed to be removed before testing could occur. The resident reported that the wax had been removed but there had been no follow-up audiology assessment afterward. The surveyor could not locate a care plan for the resident’s hearing or audiology needs in the medical record. Additional record review showed that on 6/5/26 the NP documented cerumen impaction in both ears and used Debrox to soften the wax, with occasional ear discomfort noted. The surveyor found no documentation that the wax buildup had been addressed before that date or that the audiology consult recommendations were followed up after the initial failed exam. Interviews with the SW, MR, MDS nurse, CNA, and NHA confirmed the resident remained hard of hearing, that audiology recommendations were not clearly followed through, and that the facility did not have documentation of audiology assessment follow-up for the resident.
Delayed Dental Follow-Up for Resident With Cracked Teeth and Jaw Pain
Penalty
Summary
The facility did not ensure that a resident received routine dental services after a dental referral was initiated for cracked teeth and jaw pain. The resident, who had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, depression, major depressive disorder, and anxiety disorder, reported ongoing pain with chewing and difficulty eating certain foods related to cracked crowns and missing teeth. The resident stated that a dentist had previously identified 4 cracked crowns and 2 missing teeth before admission, and that speech therapy had worked with the resident on chewing food completely, but the resident was still unable to do so because of the dental problem. A dental referral was completed on 11/11/25, but the resident was not evaluated by the dentist until 6/15/26. During that period, the resident told surveyors that they had been reporting the dental pain and chewing difficulty to the social worker for several months and had no follow-up. The resident’s nutritional evaluation documented a regular, thin liquid diet but did not address dental status or chewing difficulty, and the quarterly MDS indicated no dental concerns. The resident also reported frustration that the dental issue had not been addressed and that eating could be painful depending on the food and where it hit in the mouth. Staff interviews showed the referral and follow-up process was not effectively completed. The social worker stated that dental referrals were made through the company and that the dental report was sent to multiple staff, but could not explain why the resident waited so long for dental services. The MDS nurse was not aware of the resident’s dental concerns, the CNA was never informed of them, and the medical records/receptionist staff stated they reviewed consults but did not really read the whole consult. The nursing home administrator acknowledged there was no documentation explaining the delay in dental follow-up after the initial referral.
Failure to Document Family Notification After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to document family notification, or the resident’s wishes regarding such notification, after two of four falls experienced by one resident. The resident was admitted with osteomyelitis of the left foot, diabetic foot ulcers, and Parkinson’s disease, and had a BIMS score of 12/15, indicating moderately impaired cognition. The resident’s fall care plan, initiated due to Parkinson’s disease, weakness, non–weight-bearing status on the left lower extremity, and forgetfulness, identified the resident as being at risk for falls, accidents, and incidents. Despite this, documentation in the EMR did not reflect that the resident was asked whether he wanted his family notified following certain fall events. Review of the EMR showed that on one date the resident reported rolling from bed while repositioning, with no injuries noted, and on another date the resident was found squatting against the bathroom wall while holding onto a bar after attempting to get onto the toilet, with assessment, neuro checks, and vital signs within normal limits and no injuries noted. In both of these IDT fall notes, there was no documentation that the resident was asked if he wanted his family updated about the falls. During interview, the DON confirmed that the resident did not have a POA and was considered his own decision-maker, and that while the son was notified of one fall and the daughter was present for another, staff did not document the resident’s wishes or family notification for the other two falls. This was inconsistent with the facility’s “Notification of Changes” policy, which requires notification of the resident’s representative, if known, for significant changes in health status, including sudden illness or accident, even for mentally competent residents.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own documentation policy and accepted professional standards. For one resident with diabetic foot wounds, diabetes, and Parkinson’s disease, the EMR showed multiple missing weekly skin assessments over several months, despite the resident having diabetic foot ulcers and being frequently incontinent of bladder and always incontinent of bowel. Weekly weights were also missing on numerous dates from admission through discharge, and meal intake documentation lacked entries on many days, with no indication that meals were served or refused. Incontinent care documentation for this resident was also absent on several dates, and on one date was marked as not applicable due to an indwelling urinary catheter. For a second resident with a brain injury and severe cognitive impairment, the quarterly MDS indicated the resident was always incontinent of bowel and bladder and had no skin issues. However, weekly skin assessments were missing on multiple dates over a four‑month period. In the incontinent care task documentation, there were days within a 14‑day review period where no incontinent care was documented at all, and several days where incontinent care was documented only once per day. These gaps occurred despite the resident’s documented total incontinence status. For a third resident with multiple sclerosis who was cognitively intact and always incontinent of bowel and bladder, incontinent care documentation in the EMR showed numerous days with no incontinent care recorded. Additional days showed incontinent care documented only once on the 7:00 AM to 3:00 PM shift. During interviews, a CNA stated that documentation needed to be accurate but that many agency CNAs might not complete documentation, and the Administrator and DON confirmed there was missing documentation in resident records. The facility’s policy on documentation required that each medical record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation completed at the time of service or by the end of the shift in which care was provided, which was not followed in these cases.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the state agency within the required two-hour timeframe. The incident involved a resident who reported that a night nurse entered her room while she was on the toilet and attempted to administer medication without identifying himself or knocking. The resident expressed feeling scared and shaken by the encounter, and later reported that the nurse made a comment implying he would withhold medication in the future. The resident communicated her distress to a certified nursing assistant (CNA), who consoled her but did not witness the incident. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours after the allegation is made, especially if the event involves abuse or results in serious bodily injury. In this case, the resident informed the social worker of the incident the following evening, who then relayed the information to the nursing home administrator. The administrator and director of nursing took immediate steps to suspend the nurse and begin an investigation, but the report to the state agency was not submitted until nearly 24 hours after the facility became aware of the allegation. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and hypothyroidism, and was assessed as cognitively intact. The delay in reporting was attributed to the CNA not immediately reporting the resident's disclosure of the incident, as well as the timeline of communication between staff members. The deficiency was identified based on interviews and record reviews, which confirmed that the facility did not adhere to its own policy or regulatory requirements for timely reporting of abuse allegations.
Failure to Follow Wound Care Orders and Hand Hygiene Protocols During Pressure Ulcer Treatment
Penalty
Summary
A resident with a stage 4 pressure ulcer on the left hip was admitted to the facility and had specific physician orders for wound care, including cleaning with wound cleanser, applying Hydrofera blue into the wound, and covering with bordered gauze, to be changed three times weekly and as needed. During an observed dressing change, an LPN did not follow the current physician orders and instead packed the wound with Theraform blue soaked in Dakin's solution, contrary to the updated orders which no longer required Dakin's solution. The LPN also failed to perform hand hygiene at multiple required points during the dressing change, as outlined in the facility's policy for clean dressing changes. Interviews with the LPN, the nurse practitioner, and the nursing home administrator confirmed that the wound care provided did not align with the most recent provider orders and that hand hygiene standards were not met. The nurse practitioner clarified that Dakin's solution was no longer indicated for the resident's wound, and the administrator stated that staff are expected to follow provider orders and facility policies regarding wound care and hand hygiene. These failures were identified through observation, interview, and record review.
Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of a resident by not administering multiple prescribed medications over several days. According to the resident's Medication Administration Records (MARs) for September and October, there were multiple instances where essential medications, including a blood pressure medication (Amlodipine), a thyroid medication (Levothyroxine), a pain medication (Gabapentin), a medication for GERD (Pantoprazole), and a potassium supplement (Potassium Chloride), were not administered as ordered. The MARs showed blanks on specific dates, indicating missed doses, which was confirmed by both an LPN and the Nursing Home Administrator during interviews. Both staff members acknowledged that blanks on the MAR meant the medications were not given, constituting medication errors. The resident involved had diagnoses including hypertension, hypothyroidism, GERD, and hypokalemia, and was cognitively intact according to a recent assessment. The resident's care plan and physician orders specified the need for these medications to manage their conditions. Facility policy required medications to be administered according to physician orders and for staff to ensure accurate documentation and administration. Despite these policies, the resident did not receive their prescribed medications on at least five days across two months, as evidenced by the MARs and staff interviews.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement proper infection prevention and control measures during wound care for a resident with a stage 4 pressure ulcer on the left hip. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of both gloves and a gown during high-contact resident care activities, such as wound care. During an observed dressing change, an LPN donned gloves but did not wear a gown as required by the facility's EBP policy. After completing the dressing change, the LPN removed her gloves, handled the trash bag, exited the resident's room, and disposed of the trash outside before performing hand hygiene upon reentry. The LPN acknowledged awareness of the EBP signage and policy, which specifically stated that a gown should be worn during wound care, but admitted to not wearing a gown during the procedure. The Nursing Home Administrator confirmed that staff are expected to follow the facility's infection control standards and EBP policy during wound care. The deficiency was identified through observation, interview, and record review, and involved a resident admitted with a stage 4 pressure ulcer and physician orders for regular wound care under enhanced barrier precautions.
Failure to Implement Grievance Resolution Regarding Staff Assignment
Penalty
Summary
A resident filed a grievance regarding the conduct of a Certified Nursing Assistant (CNA), specifically concerning how the CNA spoke to the resident during care. The facility investigated the grievance and documented that the CNA would no longer be assigned to care for this resident, and this information was reportedly communicated to the scheduler. However, a review of the resident's electronic health record showed that the CNA continued to provide incontinence care to the resident on multiple occasions after the grievance was filed and the resolution was documented. Interviews with facility staff revealed that the scheduler was not informed of any restrictions regarding staff assignments for this resident, and the CNA confirmed that they continued to care for the resident, sometimes with another CNA present. The Nursing Home Administrator acknowledged an oversight in the grievance resolution process, specifically in communicating the outcome to the scheduler, which resulted in the failure to implement the agreed-upon resolution to the resident's grievance.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and functional limitations in both upper and lower extremities did not receive the necessary assistance with activities of daily living, specifically with bathing. The resident's care plan and facility policy required weekly showers, and the resident's preferences included choosing between a tub bath, shower, bed bath, or sponge bath. Documentation indicated that the resident was scheduled for showers on Tuesday mornings and required the assistance of one staff member for bathing. However, review of the electronic health record showed that the resident received only one shower in the past 30 days, with no documented refusals. Interviews with the resident and a family member confirmed that the resident had not received a shower in over two weeks and had only received bed baths, despite expressing a preference for showers. Both the Nursing Home Administrator and Director of Nursing acknowledged that residents should be offered weekly showers and that there was no reason for the resident not to have received them. The facility's failure to provide the scheduled and preferred showers as outlined in the care plan and policy led to the deficiency.
Failure to Consistently Apply Ordered Heel Protectors for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with a history of spinal cord injury, morbid obesity, quadriplegia, and a rare brain malformation was not provided with bilateral heel protectors as ordered by the physician. The resident had developed unstageable pressure injuries on both heels, and physician orders specified that heel protectors should be worn at all times, except during showers and activities of daily living, and replaced every 12 hours. Review of the Treatment Administration Record (TAR) showed that the heel protectors were only documented as being in place during two specific 12-hour periods, with no evidence of their use at other required times. The Director of Nursing confirmed that the heel protectors were not consistently applied as ordered, and documentation did not support that the resident received the prescribed pressure ulcer prevention measures. This lapse in following physician orders for pressure injury care was identified through record review and staff interview, and it affected a resident with significant risk factors for pressure injuries.
Inaccurate Daily Nursing Staff Postings for SNF
Penalty
Summary
The facility failed to ensure that the daily nursing staff posting for the skilled nursing facility (SNF) contained accurate information. The postings included hours from the community based residential facility (CBRF), and the SNF hours were either left blank or inaccurately listed the number of certified nursing assistants (CNAs) assigned during night shifts. Interviews with the receptionist responsible for the postings and the Director of Nursing (DON) revealed that the CBRF hours were routinely included on the SNF posting, and there was confusion regarding the correct number of CNAs assigned to the SNF at night. The DON stated that there are always two CNAs assigned to the SNF at night, but the postings often reflected only one or none. Further review of the facility's records showed that the daily nursing schedules and staff assignments were not maintained in written form, but instead were written on a dry erase board and erased daily, leaving no documentation of past assignments. A review of the daily nursing postings and actual staff time clock punches revealed that over a period of several weeks, there were 14 days with inaccurate nursing staff hours documented on the postings. The DON and Director of Operations acknowledged the inaccuracies and the inclusion of CBRF hours on the SNF postings.
Failure to Implement Abuse Prevention Policies and License Verification
Penalty
Summary
The facility failed to implement and enforce written policies and procedures designed to prevent abuse, neglect, exploitation, and misappropriation of resident property. Specifically, there was no effective system in place to ensure that nurses maintained a current and valid nursing license. An LPN continued to work at the facility after her license had been revoked by the Texas Board of Nursing, as the facility did not routinely verify the licensure status of agency nurses beyond the initial onboarding process. The facility's human resources and agency onboarding processes did not include ongoing checks for license validity, and the agency relied on self-reporting by the nurse for any changes in licensure status. Multiple allegations of verbal abuse and misappropriation of resident property were not reported or investigated in accordance with the facility's own policies. One resident reported verbal abuse by an LPN, but this allegation was not immediately reported to the Nursing Home Administrator or the State Survey Agency, nor was it investigated in a timely or thorough manner. In another instance, three staff members reported that a CNA was verbally abusive to a resident, but this was also not reported or investigated as required. Additionally, a resident reported missing money to a CNA, but this allegation of misappropriation was not promptly reported to the appropriate authorities. The facility's policies required immediate investigation and reporting of abuse, neglect, exploitation, and misappropriation allegations, but these procedures were not followed. Several allegations were either not reported to the required parties or not investigated in a timely and thorough manner. The lack of adherence to established policies and procedures resulted in failures to protect residents from potential abuse and exploitation, and to ensure that only properly licensed staff provided care.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in the implementation of enhanced barrier precautions (EBP) and hand hygiene protocols for four residents. Surveyors observed that required EBP signage was missing from the doors of residents who had orders or indications for EBP, including those with wounds and indwelling medical devices. In several instances, staff were unaware of which residents required EBP, and signage, when present, was not always visible to staff entering the room. Direct care staff, including LPNs, RNs, and CNAs, did not consistently wear appropriate personal protective equipment (PPE) such as gowns and gloves during high-contact care activities for residents on EBP. For example, an LPN performed wound care and G-tube flushing without donning a gown, and a CNA provided incontinence care and wound care without changing gloves or performing hand hygiene between tasks. These actions were observed despite facility policies requiring the use of gowns and gloves for EBP and proper hand hygiene before and after glove use. Interviews with the Director of Nursing, who also serves as the Infection Preventionist, confirmed expectations for hand hygiene and EBP implementation, including the need for visible signage and physician orders. However, observations revealed that these expectations were not consistently met in practice. Staff demonstrated gaps in knowledge and adherence to infection control protocols, as evidenced by their failure to perform hand hygiene at critical points and to use PPE as required by facility policy.
Failure to Provide Written Notice and Obtain Consent for Resident Room Changes
Penalty
Summary
The facility failed to provide prior written notice and obtain consent from a resident and their legal guardian before making room changes within the facility. The resident, who was cognitively intact and had a legal guardian, was transferred between rooms on at least two occasions. There was no documentation in the electronic medical record or elsewhere that the resident or their guardian received advance written notice or gave consent for these room transfers, as required by facility policy. Staff interviews confirmed that a room change form should have been completed and consent obtained, but no such documentation was found. The resident involved had multiple medical diagnoses, including cerebral infarction, hemiplegia, dysphagia, anemia, encephalopathy, bipolar disorder, anxiety disorder, and schizophrenia, and was dependent on staff for most activities of daily living. Staff interviews revealed uncertainty about the reasons for the room changes and the process followed, with some staff unaware of why the transfers occurred or whether proper procedures were followed. The facility's own policies require advance written notice and involvement of the resident and their representative in room changes, but these procedures were not followed in this case.
Failure to Notify Physician of Significant Weight Loss and Clinical Changes
Penalty
Summary
The facility failed to ensure timely physician consultation and notification regarding a resident who experienced significant weight loss, possible thrush, and issues with prescribed formula availability. The resident, who had multiple complex diagnoses including intracerebral hemorrhage, hemiplegia, chronic kidney disease, and depression, was dependent on staff for all activities of daily living and received nutrition via a gastrostomy tube. Documentation showed that the resident missed several bolus feedings due to the unavailability of the prescribed formula, and although this was eventually addressed, there was no evidence that the physician was consulted about the missed feedings or the recommendation to treat tongue thrush following a swallow study. Additionally, the registered dietitian documented significant weight loss on two separate occasions, but there was no documentation that the physician was notified or consulted regarding these changes. The facility's policy required prompt notification and consultation with the physician for significant changes in a resident's condition, but interviews and record reviews confirmed that this did not occur. Communication breakdowns between the dietitian, nursing staff, and physician contributed to the lack of timely medical intervention for the resident's significant clinical changes.
Failure to Protect Resident from Verbal Abuse Due to Delayed Reporting and Inadequate Policy Implementation
Penalty
Summary
The facility failed to protect a resident from verbal abuse by not implementing its written policies and procedures designed to prohibit and prevent abuse. A resident with severe cognitive impairment, multiple medical conditions, and total dependence on staff for care was subjected to verbal abuse by a Certified Nursing Assistant (CNA). The resident was observed crying multiple times during the morning, and when questioned, indicated through nonverbal communication that the assigned CNA was being mean and rough, and requested a different caregiver. Despite this, the CNA continued to provide care to the resident for the remainder of the shift, and the facility did not immediately initiate an investigation or remove the accused staff member from resident care duties. Further review revealed that several staff members, including two CNAs and a hospice CNA, had overheard the same CNA verbally abusing another resident weeks prior but failed to report the incident as required by facility policy. The facility's abuse prevention policy mandates immediate reporting, investigation, and protection of residents from further harm, but these steps were not followed. The accused CNA was allowed to complete the shift, increasing the risk of further abuse to other residents, and the investigation into the abuse was not started until after the CNA had left the building. Interviews with staff confirmed that the abuse allegation was not recognized or acted upon promptly by facility leadership, including the Nursing Home Administrator and Unit Manager, who did not perceive the situation as abuse when initially informed. The failure to report previous incidents and the delay in responding to the current allegation resulted in the resident being exposed to additional verbal abuse. The facility did not follow its own policies for immediate protection and investigation, nor did it ensure that staff were adequately supervised and trained to recognize and report abuse.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of abuse and misappropriation involving three residents were reported immediately to the Nursing Home Administrator (NHA) and to the State Survey Agency within the required timeframe. In the case of one resident with severe cognitive impairment and multiple medical conditions, three staff members overheard a certified nursing assistant (CNA) verbally abusing the resident, including calling the resident derogatory names. These staff members admitted they did not report the incident immediately, and the facility did not conduct a thorough investigation of the allegations at the time they occurred. Another resident, who was cognitively intact and had several chronic medical conditions, reported missing money to a CNA. The CNA documented the report, but the allegation of misappropriation was not reported to the NHA or the State Survey Agency until several days later, after the DON discovered the note in the resident's medical record. The police were eventually notified, but the delay in reporting did not meet the facility's policy or regulatory requirements for timely reporting of such incidents. A third resident, also cognitively intact, reported that a nurse had come into her room and yelled at her and her son. The resident reported the incident to a staff member transitioning to the social worker role, who then informed the DON. However, the NHA was not informed of the allegation, and the incident was not reported to the State Survey Agency within the required timeframe. The DON did not report the incident, stating that the resident did not experience ill effects. The report to the State Survey Agency was submitted after the required timeframe, and documentation of the incident was incomplete.
Failure to Timely Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse involving three residents were investigated or thoroughly investigated in a timely manner, as required by their abuse prevention policy. In the case of one resident with diabetes, hypertension, and morbid obesity, the resident reported to a social worker that a nurse had screamed at her and her son during a visit. The resident stated she reported the incident to the social worker, who did not follow up, and the Nursing Home Administrator was not informed until questioned by the surveyor. The Director of Nursing did not speak directly to the resident about the allegation and did not report the incident to the state agency, citing that the resident had no ill effects. Another resident, who was severely cognitively impaired and dependent for all activities of daily living, was observed crying and indicated through nonverbal communication that a CNA was being mean and rough. The LPN and unit manager were made aware of the situation, but the CNA continued to work the entire shift before an investigation was initiated. During the investigation, it was discovered that other staff had previously overheard the same CNA verbally abusing another resident but had not reported it. The investigation into the initial allegation was not started until after the CNA had left the building, and the facility did not act immediately to protect the resident or other residents from potential further abuse. For the third resident, who had Alzheimer's disease and severe cognitive impairment, staff statements revealed that the same CNA had called the resident derogatory names on multiple occasions, but these incidents were not reported at the time they occurred. The facility did not complete a thorough or timely investigation into these allegations. The surveyor noted that the facility's failure to promptly investigate and report these allegations, as well as to protect residents from further potential abuse, was contrary to the facility's own policies and procedures.
Failure to Provide Timely and Appropriate Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, professional standards, and the residents' comprehensive care plans for two residents with complex wound care needs. For one resident with a history of end stage renal disease, peripheral vascular disease, morbid obesity, fournier gangrene, diabetes mellitus, and idiopathic aseptic necrosis of the right finger, the facility did not complete required weekly assessments of the left scrotum surgical wound and right fifth digit wound. Additionally, wound care treatments were not consistently performed as ordered by the physician. On multiple occasions, the prescribed wound care for the right fifth digit and the left scrotum was either not completed or not performed according to the specific instructions, such as using the correct dressing materials and application methods. The resident reported to the surveyor that treatments were sometimes missed, not documented, or not performed as ordered, and that he had to remind staff to complete his care. Direct observation by the surveyor confirmed that wound care was not performed according to physician orders. For example, the nurse used alternative dressing materials without a transcribed physician order and applied tape directly to the scrotum, contrary to the physician's instructions. The nurse also failed to perform the ordered treatment for the right fifth digit during the observed care session. Review of the treatment administration record (TAR) revealed missed documentation and uncompleted treatments, with staff confirming that a blank entry indicated the treatment was not done. Furthermore, there was no evidence of weekly wound assessments for the affected areas, despite facility policy and staff statements indicating that such assessments should be completed. For another resident with multiple non-pressure wounds and a history of diabetes mellitus, atrial fibrillation, heart failure, and fractures, the facility did not perform comprehensive wound assessments upon admission. The initial head-to-toe evaluation identified multiple skin alterations, but there were no detailed descriptions or measurements of the wounds, and comprehensive assessments were not completed until six days after admission by the wound physician. Additionally, daily wound treatments ordered by the physician were not initiated until two days after admission. Staff interviews confirmed that the process for wound assessment and order transcription was not consistently followed, resulting in delays in both assessment and treatment initiation.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with multiple pressure injuries received necessary treatment and services consistent with professional standards of practice. The resident, who had diagnoses including diabetes mellitus, hypertension, morbid obesity, and was assessed as being at high risk for pressure injury development, was admitted with several existing pressure injuries. The care plan included specific interventions such as administering treatments as ordered, monitoring wound healing, and using pressure relief devices. However, the facility did not consistently implement or update treatment orders as directed by the wound physician. There were significant delays and omissions in the execution of physician-ordered wound care. On several occasions, changes to wound care orders made by the wound physician were not picked up or implemented by the facility for up to eight days. For example, treatment changes for the resident's left hip, left lateral knee, and right heel pressure injuries were not acted upon until eight days after the orders were written. Additionally, the treatment for the resident's left fifth toe was discontinued by the facility despite the wound physician's order to continue, and the new order for this site was not implemented until sixteen days later. On at least one occasion, wound care for the right heel was not completed according to physician orders, as the nurse incorrectly informed the resident that the treatment had been discontinued. Observations also revealed failures in pressure injury prevention measures. The resident was seen without pressure-relieving boots and with heels resting directly on the mattress, contrary to care plan interventions for offloading. The air mattress intended for pressure relief was repeatedly set to an incorrect, firm setting, and staff were unclear about the appropriate settings. Interviews with staff indicated a lack of clarity and communication regarding responsibility for reviewing and updating wound care orders, contributing to the lapses in care.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
A resident with a history of cerebral infarction, left-sided hemiparesis, dysphagia, and multiple psychiatric diagnoses was identified as high risk for falls and accidents. Despite this, the facility failed to provide adequate supervision and implement effective interventions to prevent repeated incidents. The resident experienced three unwitnessed falls over a period of several weeks, with no documented root cause analysis or staff statements regarding the circumstances of each fall. Additionally, there was no evidence of new, person-centered interventions being added to the care plan after these incidents, nor was there documentation of a pattern, even though two falls occurred at similar times in the evening. The resident, who was NPO and received all nutrition via a PEG tube, was mistakenly provided with a regular diet and thin liquids in the dining room. There was no documented investigation into how this error occurred or which staff were involved. Interviews with staff revealed confusion about documentation practices and a lack of clarity regarding the incident. The resident's care plan and dietary orders were not followed, and the facility was unable to produce relevant incident reports or 24-hour report sheets related to the event. Following an attempted elopement, the facility did not promptly reassess the resident for elopement risk or implement appropriate interventions. The resident was not re-evaluated for elopement risk until several days after the incident, and an elopement risk care plan was not initiated until even later. There was no documented root cause analysis or staff statements regarding the circumstances of the attempted elopement, and the facility failed to correlate the resident's repeated attempts to "go home" with both the falls and the elopement attempt. These failures demonstrate a lack of thorough investigation, pattern recognition, and timely implementation of person-centered interventions as required by facility policy.
Failure to Maintain Resident Nutritional Status Due to Missed Feedings and Lack of Physician Notification
Penalty
Summary
A resident with a history of intracerebral hemorrhage, hemiplegia, chronic kidney disease, and depression experienced significant unplanned weight loss due to missed nutritional interventions. The resident, who was dependent for all activities of daily living and received nutrition via gastrostomy tube, missed a total of seven prescribed bolus tube feedings because the required formula (Nepro) was not available. Documentation shows that staff were aware of the missed feedings, but the registered dietitian was not informed, and the physician was not notified of the significant weight loss as required by facility policy. Despite the resident's weight dropping by 5.4% in one week and 6.9% over thirty days, there was no evidence that the physician was consulted or that new interventions were added to the resident's care plan in response to these changes. Weights were not consistently obtained as ordered by the physician or as recommended by the registered dietitian, with nine scheduled weights missed. Additionally, recommendations from a swallow study to treat tongue thrush were not communicated to the physician, and no corresponding treatment order was documented. The resident's care plan was not updated to reflect the ongoing nutritional issues, missed feedings, or significant weight loss. The registered dietitian communicated significant weight loss to the nursing administration, but there was a lack of follow-through in notifying the physician and updating the care plan. The facility did not conduct a root cause analysis or revise interventions in response to the resident's deteriorating nutritional status, as required by their own policies and procedures.
Failure to Ensure Consistent Pre- and Post-Dialysis Communication
Penalty
Summary
The facility failed to ensure consistent pre- and post-dialysis communication for a resident with end stage renal disease who receives dialysis three times a week. According to the facility's own hemodialysis policy, there should be ongoing communication and collaboration with the dialysis center, including completion of dialysis communication forms before and after each treatment. However, review of the resident's medical record revealed only one dialysis communication form over a period when the resident should have had multiple treatments. The single available form was incomplete, with the post-dialysis section left blank, missing critical information such as date, time, shunt status, vital signs, and general condition. Interviews with staff indicated that the process for communicating with the dialysis center was inconsistent. Nursing staff reported that sometimes the dialysis communication forms were not sent or returned, and there was no follow-up with the dialysis center when forms were missing. The Director of Nursing confirmed that no additional forms were available for review, and other staff were unclear about the communication process. This lack of consistent documentation and communication failed to meet the facility's policy requirements for monitoring and coordinating care for residents receiving dialysis.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations revealed that EBP signs were not consistently posted on the doors of residents who required them, and staff were not always aware of which residents were on EBP. For instance, a resident with an indwelling urinary catheter and a wound did not have an EBP sign on their door, and the staff member performing wound care did not wear the appropriate personal protective equipment (PPE), such as a gown. Additionally, the facility's infection surveillance system was inadequate. The Director of Nursing, who also served as the Infection Preventionist, did not maintain a line list of residents with symptoms of infection and did not calculate or document monthly infection rates to monitor trends. This lack of documentation and monitoring hindered the facility's ability to effectively track and respond to infections, as evidenced by the absence of infection rates for the past five months and the failure to report these rates to the Quality Assurance and Performance Improvement (QAPI) committee. The facility's failure to implement and adhere to its own policies regarding EBP and infection surveillance resulted in multiple residents not receiving the necessary precautions to prevent the transmission of infections. This included a resident with severe cognitive impairment and multiple pressure ulcers who did not have an EBP sign on their door, and staff were unaware of the need for EBP. The lack of consistent signage and staff awareness, combined with inadequate infection monitoring, contributed to the facility's inability to effectively prevent and control infections among its residents.
Deficiencies in Fall and Smoking Risk Management
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and received adequate supervision and assistance devices to prevent accidents. This deficiency was observed in several residents who experienced falls that were not thoroughly investigated, and their care plans were not promptly revised. For instance, a resident had a fall that was not investigated until several days later, and the care plan was not updated immediately to include new interventions. Another resident's fall investigation lacked staff interviews and did not document when the resident was last checked or toileted. Additionally, the facility did not adequately manage a resident's smoking habits. The resident was assessed as needing supervision while smoking, yet there was no smoking care plan in place, and the resident had access to smoking supplies in their room. The facility's policy required that smoking materials be stored by the staff, but this was not adhered to, and the resident's smoking status was not consistently documented in their care plan or CNA care card. The facility's investigation process for falls was found to be lacking, as several fall incidents did not include comprehensive statements from staff or residents, and critical sections of the fall investigation templates were left blank. In some cases, identified environmental hazards, such as poor lighting, were not addressed in the residents' care plans. The lack of thorough investigation and timely updates to care plans indicates a systemic issue in the facility's approach to managing fall risks and ensuring resident safety.
Failure to Provide Adequate Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, whose primary language is Serbian, was fully informed of their health status and care in a language they could understand. The resident, identified as R235, was admitted with conditions including vascular dementia and type 2 diabetes. Despite being cognitively intact, the facility did not provide adequate communication methods or resources for R235, relying instead on family members for translation. This reliance on family members for communication was against the facility's policy, which states that family should not be the primary source of translation unless explicitly requested by the resident. The facility's care plan for R235 did not include interventions or resources for effective communication in Serbian. The care plan inaccurately listed a son as the translator, although no son was documented in the resident's contact list. Staff members were unaware of available resources, such as translation applications or communication boards, and instead used hand gestures or relied on the resident's family for communication. This lack of proper communication resources and training led to the resident not being fully informed about their medical condition and care. Interviews with staff revealed a lack of awareness and training regarding alternative communication methods for residents with limited English proficiency. The facility's failure to provide appropriate translation services and resources resulted in the resident's inability to effectively communicate their needs and understand their health status. The deficiency was noted by surveyors, who highlighted the inadequacy of the care plan and the inappropriate reliance on family members for translation.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices to two residents, R12 and R23, when they were hospitalized. R12, who had a healthcare Power of Attorney (POA) for medical decisions, experienced a change in condition and was transferred to the hospital. Despite requests from the surveyor, the facility could not provide evidence that a transfer notice was given to R12 or R12's POA. The Unit Manager and Licensed Practical Nurse (LPN) indicated that nurses were responsible for handling transfer notices, but there was a lack of understanding and execution of this responsibility. The Director of Nursing (DON) acknowledged that notifications were typically made via phone calls rather than in writing. R23, who had severe cognitive impairment and an activated POA, was transferred to the hospital six times over a three-month period. The facility provided bed hold notices but failed to include written information about the reasons for each transfer. The contact information for the State Long-Term Care Ombudsman and the State of Wisconsin Division of Quality Assurance was incomplete. Interviews with staff revealed a similar pattern of verbal notifications without written documentation, and the DON confirmed that written notices were not provided but would be in the future. The deficiency highlights a systemic issue within the facility regarding the failure to provide required written transfer/discharge notices, which include essential information such as the date, reason, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This oversight was consistent across multiple instances and involved both residents reviewed for hospitalizations, indicating a need for improved adherence to regulatory requirements for resident notifications.
Inconsistent Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure injuries, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including malnutrition, osteoporosis, and vascular dementia, was at risk for pressure injuries and had existing pressure injuries that required consistent care. Despite this, the resident did not receive treatment for a lower back pressure injury on 20 out of 71 days, and there was no documentation of multiple skin discolorations over bony prominence areas where pressure injuries are likely to occur. The surveyor observed that the resident's lower back pressure ulcer increased in size over 14 weeks, from 1 x 3 x 0.1 cm to 6 x 4 x 0.5 cm. The facility's treatment administration records indicated that the resident did not receive wound care on several occasions across different months, with specific gaps noted in October, November, December, and January. Additionally, during an observation, a Licensed Practical Nurse performed wound care wearing only gloves, and multiple small, purple discolorations were noted on the resident's heels and feet, which were not documented. The Director of Nursing acknowledged the missing wound treatments and the lack of documentation regarding the skin discolorations. The resident was receiving palliative care, and the facility focused on addressing larger pressure ulcers causing the most pain, while other areas were to be monitored. However, the failure to consistently provide wound care and document skin conditions contributed to the deficiency identified by the surveyor.
Failure to Ensure Appropriate Contracture Management
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. The resident, who has hemiplegia following a stroke, was observed not wearing the prescribed splint or palm guard on multiple occasions during the survey. The resident's care plan did not include the use of a splint or palm guard as an intervention, despite a physician's order for a resting hand splint to be worn on the right hand for six hours daily. The Treatment Administration Record (TAR) showed numerous instances where staff did not document the application of the splint as ordered. Occupational Therapy (OT) notes indicated that the resident was hesitant to wear the splint and experienced skin issues, leading to a change in the contracture management plan from a splint to a palm guard. However, this change was not communicated to update the physician's order or the care plan, resulting in a lack of consistent application of the palm guard. Interviews with staff revealed a lack of awareness and communication regarding the resident's current contracture management plan. The Director of Nursing acknowledged that the change from a splint to a palm guard was not communicated effectively to the nursing staff, contributing to the deficiency in providing appropriate care to maintain or improve the resident's range of motion.
Failure to Provide Timely Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care consistent with professional standards for a resident admitted with a colostomy. The resident, who was admitted on October 25, 2024, did not have physician orders for colostomy care until January 7, 2025, approximately 10 weeks after admission. During this period, there was no consistent documentation of the necessary care and services for the resident's colostomy. The facility's policy requires that ostomy care be provided by licensed nurses under the orders of the attending physician, including specific instructions on the type of ostomy, frequency of pouch change, and type of equipment. However, these orders were not in place until well after the resident's admission. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that there was an expectation for a physician order for colostomy care, which was not met in this case. The resident expressed concerns about the colostomy care received, indicating that care was lacking at the beginning of their admission. The facility's documentation showed only one instance of colostomy care being provided on November 12, 2024, with no further documentation until after the physician order was placed in January. This lack of timely and consistent care documentation highlights a deficiency in adhering to the facility's policy and professional standards of practice for colostomy care.
Failure to Provide Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R485, who required such services. Upon admission, R485, who had a history of end-stage renal disease and other significant health conditions, did not have physician orders for hemodialysis or a care plan in place for monitoring and managing dialysis-related complications. The facility's policy required ongoing evaluation and communication with the dialysis center, but these were not documented in R485's electronic medical record. The surveyor found that there was no evidence of assessments being completed before or after dialysis sessions for R485. Additionally, there was a lack of documentation regarding communication between the facility and the dialysis center. Only one partially completed dialysis communication form was provided, despite R485 having undergone multiple dialysis sessions. The facility's Director of Nursing acknowledged the absence of a care plan and physician orders specific to R485's dialysis needs. The surveyor noted that the facility's failure to ensure proper documentation and communication regarding R485's dialysis care was inconsistent with professional standards of practice. This deficiency was highlighted by the absence of physician orders, care plans, and completed assessments, which are necessary to monitor the resident's condition and prevent complications associated with dialysis treatment.
Inappropriate Transfer Assistance by Unqualified Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets necessary to care for a resident's needs, specifically affecting one resident (R29) out of twelve reviewed. R29, who has multiple sclerosis, generalized anxiety disorder, and recurrent depressive disorder, was assessed to require a sit-to-stand mechanical lift for transfers. However, it was observed that a Resident Assistant (RA-T), who is not a certified nursing assistant (CNA) and works in the community-based residential facility (CBRF) side of the facility, was assisting R29 with pivot transfers into a wheelchair to go outside for smoking. This assistance was contrary to the care plan, which specified the need for a mechanical lift for transfers. The surveyor's review of the facility's staffing list and RA job description revealed that RA-T was not employed to assist residents on the long-term care side of the building and was not certified to provide such care. The Director of Nursing (DON) confirmed that RA-T should not assist residents alone and that the RA job description did not include assisting CNAs with long-term care residents. The deficiency was identified when the surveyor observed and interviewed R29, who confirmed the assistance provided by RA-T, which was not in line with the resident's assessed needs and care plan.
Failure to Administer Medication Safely and Accurately
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident diagnosed with human immunodeficiency virus (HIV) disease, resulting in five missed doses of Epoetin Alfa Injection Solution. The resident, who was cognitively intact and suffering from severe depression, had a physician's order for the medication to be administered subcutaneously at bedtime every Tuesday, Thursday, and Saturday for anemia related to HIV disease. However, the medication was not available after the resident's admission, leading to missed doses on five separate occasions. The surveyor's findings revealed that there was no documentation indicating that the physician or pharmacy was contacted regarding the unavailability of the medication. Interviews with the registered nurse and the Director of Nursing confirmed that the medication was pending delivery and that the protocol for such situations involved notifying the physician and contacting the pharmacy. However, there was no policy in place addressing missed medication doses, and the facility failed to follow the protocol, resulting in the deficiency.
Failure to Act on Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to act upon pharmacy medication regimen review reports for a resident, identified as R21, who was admitted with diagnoses including dementia, traumatic brain injury, epilepsy, anxiety, and depression, and was receiving hospice services. The pharmacy reviews for R21, dated 9/10/2024 and 11/11/2024, included recommendations for medication adjustments that were not acted upon by the attending physician until prompted by the surveyor. These recommendations included adding a stop date for PRN Ativan, adjusting the dosing schedule for zonisamide and topiramate to reduce medication pass burden, and ensuring compliance with CMS guidelines for PRN psychotropic medications. The surveyor's review revealed that the facility's process for handling pharmacy recommendations was not followed, as the recommendations were not reviewed or acted upon in a timely manner. The Director of Nursing (DON) acknowledged the process involves receiving recommendations via email, which are then given to the physician for review and order changes. However, the DON was unsure why R21's recommendations were not addressed until the surveyor's intervention. The physician only signed the recommendations and issued new orders on 1/27/2025, after the surveyor requested documentation, indicating a lapse in the facility's medication review process.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring for adverse reactions of high-risk medications for two residents, R31 and R485, who were prescribed anticoagulants and diuretics. R31, who was admitted with conditions including chronic embolism, thrombosis, and hypertension, was prescribed Eliquis and Furosemide. However, the facility did not implement a care plan to monitor for potential adverse side effects from these medications. During an interview, the Director of Nursing (DON) acknowledged the absence of a care plan for R31, which was contrary to the facility's policy on managing high-risk medications. Similarly, R485, who was admitted with end-stage renal disease and other chronic conditions, was prescribed Apixaban and Furosemide. The facility also failed to create a person-centered care plan to monitor for adverse effects of these medications. The DON confirmed the lack of a care plan for R485 during an interview, admitting that both residents should have had care plans in place according to the facility's policy. This oversight indicates a failure to adhere to the established guidelines for managing high-risk medications, potentially compromising resident safety.
Deficiencies in Psychotropic Medication Monitoring and PRN Order Compliance
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for a resident receiving psychotropic medications. The resident, identified as R485, was prescribed Mirtazapine and Seroquel for depression and mood disorder but did not have orders for monitoring adverse effects or non-pharmacological interventions. Despite the resident's severe depression and complaints of not being listened to, there was no documentation of behavior monitoring or effectiveness of the medications. The staff acknowledged the lack of monitoring and stated that the resident often ignored them, complicating efforts to address the resident's mental health needs. Another deficiency was identified concerning the administration of PRN psychotropic medication for a resident, R21, who was prescribed Lorazepam for anxiety, restlessness, agitation, and seizures. The medication order did not include an end date, which is against the facility's policy that requires PRN orders to be limited to 14 days unless a rationale and duration are documented. The oversight was acknowledged by the Director of Nursing and the Nursing Home Administrator during the surveyor's review. The facility's policy on the use of psychotropic medications emphasizes the necessity of monitoring and documentation of the resident's response to medications, as well as the implementation of non-pharmacological interventions. However, the facility failed to adhere to these guidelines for the residents reviewed, leading to deficiencies in the care provided. The lack of monitoring and documentation for both residents highlights a significant gap in the facility's compliance with its own policies and regulatory requirements.
Failure to Administer Consented Vaccinations
Penalty
Summary
The facility failed to ensure that residents received the influenza and pneumococcal immunizations as per their consent, resulting in a deficiency. Specifically, two residents, identified as R37 and R23, consented to receive the influenza and pneumococcal vaccines, respectively, but did not receive them. The facility's policy, dated May 16, 2023, mandates that residents be offered these vaccines unless contraindicated or already received elsewhere, and that documentation should reflect the education provided and the administration of the vaccines. During interviews conducted on January 23, 2025, the Director of Nursing (DON), who also serves as the facility's Infection Preventionist, acknowledged that R37 had not received the influenza vaccine and R23 had not received the pneumococcal vaccine. The DON indicated that they believed the influenza vaccine was in stock for R37 and that the pneumococcal vaccine needed to be ordered for R23. However, there were no orders for the administration of these vaccines in the residents' medical records, highlighting a lapse in the facility's adherence to its immunization policy.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident, identified as R235, to the State Survey Agency. The incident occurred during the night shift on January 8, 2025, when R235's family member reported that the resident was left wet and unattended for several hours. Despite the family member's attempts to contact the facility, the phone was reportedly not answered, prompting the family member to visit the facility in person. Additionally, the family member reported that staff were rude and dismissive during interactions. The Nursing Home Administrator (NHA) did not report these allegations to the State Survey Agency as required by the facility's policy. R235, who was admitted to the facility with diagnoses including vascular dementia, type 2 diabetes, and bradycardia, was assessed as needing extensive assistance with personal care tasks. The resident's family member had previously reported similar concerns about neglect and staff behavior on January 3 and 4, 2025. When questioned by the surveyor, the NHA stated that staff claimed the family member was rude and that rounds were being completed every two hours. However, the NHA did not verify whether the facility phone was operational or if rounds were conducted as reported. This lack of verification and failure to report the neglect allegations constituted a deficiency in the facility's compliance with its abuse prevention policy.
Inadequate Investigation of Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving two residents, R7 and R30, which was reported to the State Survey Agency. The incident occurred when R7 entered the room to use the restroom and R30's hand connected with R7's shoulder. The facility's documentation of the incident was inconsistent with R7's account, who reported that R30 hit him with a fist. The investigation lacked comprehensive interviews with other staff or residents who might have witnessed the incident, and there was no verification of the events as described by the involved parties. Additionally, the facility did not adequately investigate an allegation of neglect reported by R235's family member. The family member reported that R235 was left wet and unattended during the night, and staff were unresponsive to phone calls. The investigation did not include statements from all relevant staff, and there was no documentation verifying that regular rounds were conducted as claimed. The facility also failed to recognize these concerns as potential neglect, and there was no evidence that the phone system was checked for missed calls. The facility's policies on abuse, neglect, and exploitation require immediate and thorough investigations of such allegations, including interviews with all involved parties and complete documentation. However, in both cases, the investigations were incomplete, lacking necessary interviews and documentation to substantiate the claims or to ensure that appropriate measures were taken to prevent recurrence.
Failure to Designate Charge Nurse for Each Shift
Penalty
Summary
The facility failed to ensure that sufficient nursing staff was provided to meet the needs of all residents, as evidenced by the lack of a designated charge nurse for each shift. This deficiency was identified through observation, interviews, and record reviews conducted by the surveyor. The surveyor requested nursing schedules and staff postings for a specific period due to concerns about low weekend staffing reported in the Payroll Based Journal. Upon review, it was noted that the facility's nursing schedules did not specify who the charge nurse was for each tour of duty. During an interview, the Director of Nursing (DON) acknowledged responsibility for coordinating the nursing schedule and preparing staff postings. However, the DON admitted to being unaware that the schedules lacked a designated charge nurse for the specified period. The Nursing Home Administrator was informed of this issue, but the facility did not provide any additional information or justification for the oversight. This deficiency potentially affected all 39 residents residing in the facility.
Omission of Daily Census in Nurse Staff Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staff postings included all required information, specifically the daily resident census. This deficiency was identified during a survey when the surveyor requested nursing schedules and nurse staff postings for a specific period due to concerns about low weekend staffing reported in the Payroll Based Journal. Upon review, it was noted that the facility's postings did not include the daily census number for the specified periods. During an interview, the Director of Nursing (DON) acknowledged the omission and stated that they would add the daily census information to future postings. The Nursing Home Administrator was also informed of the concern, but no additional information was provided by the facility at that time.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for five residents who required such measures due to the presence of wounds, indwelling urinary catheters, or gastrostomy tubes. Observations revealed that rooms lacked signage indicating the type of personal protective equipment (PPE) required for direct care, and physician orders for EBP were absent for these residents. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that EBP were not being applied, and staff were not using PPE when providing care to residents with catheters, wounds, or gastrostomy tubes. Additionally, the facility failed to adhere to proper infection control practices during incontinence care for one resident. A Certified Nursing Assistant (CNA) was observed not changing gloves between cleaning the resident's perineal area and applying a clean incontinence brief. This practice was confirmed by the CNA and the DON, who acknowledged that the expectation was to change gloves after removing a soiled brief before applying a clean one. The deficiency in infection prevention and control practices was further corroborated by the facility's administration, who confirmed the absence of necessary signage and the failure to follow proper infection control protocols. These lapses in protocol increased the potential for cross-contamination and transmission of multidrug-resistant organisms among residents.
Deficiencies in Transcription and Administration of Physician Orders
Penalty
Summary
The facility failed to ensure professional standards of care were met in the transcription and administration of physician orders for wound care and antibiotics. For one resident, the wound care physician's orders for treating skin wounds were not properly reviewed or documented in the electronic medical record (EMR), leading to a lack of necessary dressing changes. The resident, who was admitted with conditions including moderate protein-calorie malnutrition and quadriplegia, had documented skin alterations that were not adequately described or addressed in nursing assessments. The Director of Nursing (DON) confirmed that the orders were missing from the EMR, resulting in the omission of wound treatments. Another resident experienced a failure in the transcription of antibiotic orders following a hospital readmission. The resident, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was prescribed antibiotics for aspiration pneumonia. However, the medication was not transcribed into the resident's chart, and the resident did not receive the prescribed antibiotics. The DON confirmed that a transcription error occurred, and the medication order was not completed in the Point Click Care (PCC) system. Interviews with the DON revealed systemic issues in the transcription process for both wound care and medication orders. The DON acknowledged a break in the system for transcribing orders from the wound care provider to the EMR, as well as a failure to complete the antibiotic order in the PCC system. These deficiencies resulted in the potential for decreased healing and harm due to the lack of treatment and administration of necessary medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 738 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muskego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tudor Oaks Health Center | 0 mi | ★★★★★ | 1 | 0 |
| Complete Care At Hales Corners | 6.1 mi | ★★★★★ | 5 | 0 |
| Lindengrove New Berlin | 7.1 mi | ★★★★★ | 5 | 1 |
| Clement Manor Health Care Center | 7.4 mi | ★★★★★ | 20 | 1 |
| Greendale Park Nursing And Rehab | 8.2 mi | ★★★★★ | 43 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Muskego Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.