Lindengrove Menomonee Falls: Gown Shortage Cited - WI
Federal inspectors documented the shortage after a survey completed March 3, 2025. The finding was rated at the minimal harm level, affecting some residents. What it captured, in plain terms, was a facility that ran out of a basic item residents had specifically asked for and could not fully account for how that happened or when it was fixed.
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See the Derila PillowThe Director of Nursing and the nursing home administrator both acknowledged the problem to inspectors. Over the weekend and into Tuesday, they said, there were no gowns available on either the upstairs or downstairs units. Residents who preferred to sleep in gowns could not have them. Neither offered inspectors any further information about the shortage.
That was the extent of what the facility provided.
The inventory count for gowns, inspectors learned, was done on a biweekly schedule. The last count before the shortage was noted had been completed February 10. The gap between that count and when the shortage surfaced was at least three days, possibly longer. Nobody caught it in between.
A shortage of sleep gowns is not, on its face, a catastrophic failure. The inspectors themselves rated the harm as minimal. But what the record shows is a facility where a routine supply item ran out across two entire floors, residents who had expressed a preference went without it for multiple days, and when inspectors asked what happened, the people running the facility had nothing more to say.
Resident preference in a nursing home is not a small thing. For people who have given up their homes, their schedules, and much of their daily independence, the ability to sleep in the clothing they choose is one of the few remaining expressions of personal control. When that preference is documented and then unmet because nobody tracked the supply closely enough, it is a specific kind of failure, even if a quiet one.
The biweekly inventory system meant that in the best case, a shortage could go undetected for up to two weeks before anyone with a counting clipboard would notice. In this instance, the shortage became visible because residents and staff flagged it over a weekend, not because the system caught it. The last formal count had been done more than three days before the problem surfaced. There was no indication inspectors received of any interim check, any backup process, or any protocol for what staff should do when a supply ran short between scheduled counts.
The Director of Nursing and the administrator were both aware of the situation by at least February 13, when the inspection note was recorded at 3:04 in the afternoon. What either of them did in response, whether gowns were ordered, whether residents were told anything, whether the inventory schedule was reviewed, the inspection report does not say. The facility provided no further information.
For a resident at Lindengrove Menomonee Falls who wanted a gown and spent several nights without one, the inspection report that resulted will show a minimal harm citation. The box will be checked. The plan of correction, if anyone asks for it, would need to be obtained from the facility or the state survey agency directly, because the report itself contains none.
What the report does contain is a two-sentence account from the people in charge of the building: there were no gowns, on either floor, for several days. That is all they had to offer.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 13, 2026 · Our methodology
Lindengrove Menomonee Falls in MENOMONEE FALLS, WI was cited for violations during a health inspection on March 3, 2025.
Federal inspectors documented the shortage after a survey completed March 3, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.