Federal inspectors found Lindengrove Menomonee Falls failed to implement basic fall prevention measures for six residents who suffered repeated accidents, including one who required emergency room treatment and stitches after hitting his head on a wooden side table.
R12, a hospice patient with vascular dementia, fell on September 12, September 26, and December 11. Her care plan required a body pillow and floor mat whenever she was in bed. During the February inspection, surveyors watched nursing assistants leave the body pillow propped against a recliner in the corner and the floor mat stored against furniture instead of beside her bed.
On February 11, surveyor observed certified nursing assistant CNA-K caring for R12. After helping her with personal care, CNA-K lowered the bed and left the room without placing either the body pillow or floor mat in position. When the surveyor returned at 2:44 p.m., R12 was awake in bed but the mat remained propped against the recliner.
"You don't know what will happen, a fall can happen that quick," registered nurse RN/WN-I told the surveyor when asked whether fall interventions should be in place.
The facility's investigations into R12's falls were inadequate. For her September 26 fall, when she was found face-down complaining of head and shoulder pain, inspectors found no staff statements about when she was last seen or whether safety measures were in place. The December 11 investigation noted the floor mat wasn't positioned and the bed wasn't at the lowest setting, but failed to document whether the body pillow was being used.
R23, another hospice resident with severe cognitive impairment, fell four times between November and January. She sustained a head laceration requiring a hospital visit on December 13 when she hit her head on a wooden side table while getting dizzy during a transfer. Despite her care plan requiring transfers with a gait belt, inspectors observed CNA-K transferring her without one.
"Just walker, used to be in care plan but hospice took it out," CNA-K told the surveyor when asked about gait belt use, though the resident's current care plan still required it.
During R23's January 21 fall, she was found face-down with a large knot above her right eye. The facility's investigation contained conflicting information from staff, with one aide stating she last saw the resident at 8:00 p.m. but also claiming the call light wasn't on because she was in the room when the fall occurred at 8:50 p.m.
Director of Nursing DON-B acknowledged the contradiction when interviewed. "I didn't ask her," DON-B said when the surveyor asked whether she had clarified if the aide was actually present during the fall.
Another resident sustained a laceration requiring stitches after an unwitnessed fall on January 23. His fall investigation documented only that he was "trying to get up to use the toilet" but included no information about when he was last toileted or what circumstances led to the accident.
The facility's fall prevention policy requires licensed nurses to complete electronic incident reports, update care plans with interventions, and conduct root cause analysis through the interdisciplinary team. However, inspectors found investigations consistently lacked basic information about circumstances preceding falls and whether existing safety measures were implemented.
R36's care plan required his call light to be within reach, but inspectors observed it was not accessible during their visit.
The facility also failed to designate charge nurses on daily schedules from July through September 2024 and from January 20 through February 10, 2025. Scheduler HHH told inspectors they were unaware this was a requirement.
Food safety violations compounded the problems. Kitchen staff worked without required hair restraints, with one dietary aide's beard completely uncovered while handling food. The dishwashing machine's sanitization wasn't monitored for months at a time, with temperature logs missing for September, November, and December 2024.
Staff delivered meal trays to resident rooms with uncovered food items, carrying them up to three rooms away from carts. When asked about the practice, Regional Food Service Director RFSD-Z acknowledged the concern but said only hot entrees receive covers.
The inspection also cited the facility for immediate jeopardy related to pressure ulcer care for a newly admitted resident, though details of that violation were not fully documented in the available report.
Lindengrove Menomonee Falls houses 49 residents. The facility did not provide additional information to address the deficiencies identified during the March 3 complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lindengrove Menomonee Falls from 2025-03-03 including all violations, facility responses, and corrective action plans.
