Milwaukee Health and Rehab

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (R11) of 14 residents reviewed for Activities for Daily Living (ADL).*R11 was observed to be double briefed during incontinence cares.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R45) of 1 resident receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.*R45 was observed to not have a splint in place for R45's right hand.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 56 residents residing in the facility. Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

Inspectors wroteBased on interviews and record review, the facility did not ensure allegations of verbal abuse were immediately reported to the Administrator. This was observed with 1 (R1) of 1 resident reviewed for allegations of verbal abuse. On 6/29/2025 staff and R1 heard Registered Nurse (RN)-D call R1 a dizzy bitch around 9:30pm. The verbal abuse was observed by other staff but not reported to Nursing Home Administrator (NHA)-A until the following morning on 6/30/2025. RN-D continued to finish RN-D's shift which ended at 11:00pm.

Inspectors wroteBased on interview and record review, the facility did not ensure the safety and supervision of 1 (R1) of 1 resident reviewed for supervision and accidents. On 6/28/2025 while sitting outside R1 asked another resident to push them to the store. The other resident began to push R1's wheelchair to the store. The facility did not re access R1 for elopement risk, ability to leave the facility unsupervised, or initiate a care plan to prevent future incidents from happening.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure hospital physicians orders were implemented for one of one resident (Resident (R) 1) reviewed for implementation of physician orders out of a survey sample of nine. Specifically, the facility failed to obtain a laboratory blood test for vitamin D (to determine low bone density, fatigue, bone pain). In addition, the facility failed to coordinate services with R1's responsible party to ensure that one medical appointment was to be scheduled after the resident was discharged by the hospital and readmitted back to the facility. This failure had the potential for the resident to not receive appropriate continuum of care. (Cross Reference F690 and F692)

Inspectors wroteBased on record review, interviews, and review of the facility's policy, the facility failed to ensure one of nine sampled residents (Resident (R)1) had a bowel program implemented. This deficient practice may result in bloating, pain, and general discomfort.

Inspectors wroteBased on record review, observation, staff interviews, and facility policy review, the facility failed to assess nutritional status after a significant weight gain and loss and failed to take corrective action after the facility determined the weight gain and loss was an error for one of one resident (Resident (R) 1) reviewed for nutrition in a total sample of nine residents.

Inspectors wroteBased on interviews and record review, the facility did not implement their water management plan based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of waterborne pathogens. This deficient practice has the potential to affect all 64 residents. The facility's water heating system stopped working on 8/10/2024. The facility was without hot water from 8/10/2024 - 8/15/2024. ~The facility did not call a contracted company to come to the facility to assess the concern until 8/12/2024 and the contracted company did not get to the facility until 8/14/2024 to assess and fix the concern. ~Water temperatures and testing were not completed during the time the water heater system was not working (8/10/2024 - 8/14/2024) and the facility did not take corrective actions when control limits were not met.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all 66 residents residing in the facility at the time of this survey. *On 7/23/24 at 11:07 AM, Surveyors conducted the resident council interview task. R58 shared with surveyors that night shift at the facility is like a ghost town due to lack of staff. R58 shared that they have had their call light unanswered for almost an hour at times. R58 told Surveyor that they have been afraid at times that they would be incontinent of bladder due to waiting for toileting assistance but were able to hold their bladder. [...]

Inspectors wroteBased on observation and interview the facility did not ensure residents had a safe, clean, comfortable and homelike environment for 1 of 2 shower rooms observed in the facility. On 7/23/24, at 10:55 AM, Surveyor observed the 2nd floor shower room had yellow tape across the door and a sign that read out of order. All facility residents that required showers had to use the 3rd floor shower room which was not maintained in a hygienic manner.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents who enter the facility with an indwelling catheter are assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary and residents received appropriate treatment and services to restore continence to the extent possible for 1 of 2 (R55) residents reviewed for catheters. R55 had Urologist orders that were not followed.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by reporting 3 of 5 allegations of abuse (slap in face, kicked, and slapped) to law enforcement and immediately reporting 5 of 5 allegations of abuse to the State Survey Agency for 1 of 5 (R1) residents reviewed for abuse. * On 10/8/2023, R1 and R1's family member made an allegation of R1 being slapped on the face. Registered Nurse (RN-C) did not immediately notify the Administrator of this allegation of abuse. This allegation of abuse was not reported to the State Survey Agency until 10/9/2023. This allegation of abuse should have been reported to the State Survey Agency no later than 2 hours after the allegation was made. [...]

Inspectors wroteBased on staff interviews and record review the facility did not ensure allegations involving abuse were thoroughly investigated for 1 (R1) or 5 residents reviewed for abuse. On 10/12/2023 Law Enforcement arrived at the facility due to the hospital reporting potential abuse to R1 upon arrival to the emergency room with bruising to R1's eye, sternum, and leg. The abuse allegation was not in itself investigated by the facility but instead was mentioned within an investigation pertaining to a different allegation made on 10/8/23 regarding R1 being slapped. There was no staff interviews pertaining to the R1 having been identified on 10/12/23 with bruising of unknown orgin to the right eye, sternum, and R leg upon arrival to the hospital.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure timely reporting of an allegation of verbal abuse to facility administration related to one (Resident (R) 15) of 17 residents reviewed in the sample.

Inspectors wroteBased on interview and record review, the facility did not ensure 5 (R26, R47, R33, R17, and R48) of 5 residents reviewed that required hospitalizations were given a written reason for transfer to the hospital. Before being transferred to the hospital, the facility did not notify the resident and/or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility did not record the reasons for the transfer or discharge in the resident's medical record. R33, R17, R26, R47 and R48 and/or their resident representative did not receive written notice of the reason for transfer prior to their transfer to the hospital.

Inspectors wrote3. Surveyor conducted a review of R26's medical record on 04/11/23. The medical record indicated R26 was transferred to the hospital on 4/5/23. R26's medical record did not include documentation that a written notice of the bed hold policy had been given to the resident and/or representative for the hospitalization. On 4/12/23, at 10:30 AM, the Corporate Consultant-D was interviewed and indicated a bed hold notice was not completed for R26 on 3/29/23 and should have been.

Inspectors wroteBased on observation and interviews the facility did not ensure each resident received food that is palatable and at an appetizing temperature for 4 of 4 (R28, R36, R48 and R53) R48 reported they receive cold eggs with breakfast. Resident Council participants (R28, R36 and R53) reported room meal trays are served cold. Findings Include: R48 admitted to the facility on [DATE] and has a Brief Interview for Mental Status (dated 3/27/23) of 13, indicating no cognitive impairment. On 4/10/23, at 9:43 AM, R48 reported she eats breakfast in her room and sometimes eats in the dining room for other meals. R48 reported she eats eggs every day and they are always cold. Surveyor asked if staff will reheat food. R48 stated: I suppose so, but they have a lot of people, it would take too long. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 1 (R9) of 2 residents reviewed for range of motion. R9 was observed not wearing left hand palm splint for three days of survey.

Inspectors wroteBased on record record review and staff interviews, the facility did not ensure that 1 (R8) out of 1 resident 's reviewed with significant weight loss were provided with nutritional care and services to maintain acceptable parameters of nutritional status based on a comprehensive assessment. On 12/9/22, R8 weighed 212 pounds. On 1/6/23, R8 weighed 198 pounds, which was a significant weight loss of 14 pounds in 1 month. On 2/23/23, R8 was documented to weigh 179. This further weight loss of 19 pounds is a significant weight loss. As of 4/13/23, R8 weighed 178 pounds and did not have any further comprehensive assessment of their significant weight loss. The facility did not revise the plan of care to identify if this weight loss was desirable or physician prescribed or identify additional interventions to help R8 maintain weight if the weight loss was not desired. [...]

Inspectors wroteBased on record review and interview, the facility did not offer the influenza and/or pneumococcal immunizations for 3 (R10, R15 and R29) of 5 residents reviewed for immunizations. * R10 was not offered the pneumococcal immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. * R15 was not offered the influenza immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. * R29 was not offered the Prevnar 13 immunization on admission to the facility and the facility did not document if the immunizations were offered and declined.