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.
23
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

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

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

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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Which alerts

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

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility23WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility23
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
62022-0692023-0982025-01
Citations at each Life Safety survey
Survey dateCitations
June 8, 20226
September 28, 20239
January 27, 20258

Most-cited tags

Most-cited tags at this facility
K-03533K-03452K-02222K-02931K-07121K-05311K-03431E-00351
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32025-01-27
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22023-09-28
K-0222Add 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.22025-01-27
K-0293Have properly located and lighted "Exit" signs.12022-06-08
K-0712Have simulated fire drills held at unexpected times.12025-01-27
K-0531Have elevators that firefighters can control in the event of a fire.12023-09-28
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.12023-09-28
E-0035Provide family notifications of emergency plan.12025-01-27

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 12
  • Egress Deficiencies 4
  • Emergency Preparedness Deficiencies 2
  • Miscellaneous Deficiencies 2
  • Other 3
Citations by CMS category
CategoryCitations
Smoke Deficiencies12
Egress Deficiencies4
Emergency Preparedness Deficiencies2
Miscellaneous Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies2
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 27, 2025 — 8 citations

Citations issued on January 27, 2025
TagWhat the surveyor checksStatus
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (February 26, 2025)
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (February 26, 2025)
K-0222Add 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-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 26, 2025)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (February 26, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (February 26, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (February 26, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (February 26, 2025)

September 28, 2023 — 9 citations

Citations issued on September 28, 2023
TagWhat the surveyor checksStatus
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (September 28, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 31, 2023)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (October 17, 2023)
K-0343Have 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-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 31, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 31, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 2, 2023)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (October 17, 2023)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (September 27, 2023)

June 8, 2022 — 6 citations

Citations issued on June 8, 2022
TagWhat the surveyor checksStatus
K-0222Add 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-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (July 1, 2022)
K-0321Ensure 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-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (July 1, 2022)
K-0346Follow 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-0353Inspect, 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.