Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Muskego Health and Rehabilitation Center
MUSKEGO, WI · 49 certified beds · Last Life Safety survey January 27, 2025
CMS Certification Number 525686 · first certified August 2006
Ownership
Operated by CHAMPION CARE · For profit - Individual
- Ownership changed June 1, 2022 (change of ownership)from MUSKEGO NURSING HOME INC.
Position within WI
23 citations — more than 67% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to May 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 8, 2022 | 6 |
| September 28, 2023 | 9 |
| January 27, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-01-27 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-09-28 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2025-01-27 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2022-06-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-01-27 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2023-09-28 |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | 1 | 2023-09-28 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2025-01-27 |
What the citations cover
- Smoke Deficiencies 12
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Miscellaneous Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 27, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (February 26, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 26, 2025) |
September 28, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 31, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 17, 2023) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (October 17, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 31, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 31, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 2, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (October 17, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (September 27, 2023) |
June 8, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 1, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 1, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 1, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 1, 2022) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (July 1, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 6, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.