Lindengrove Menomonee Falls: Immediate Jeopardy Violations - WI
Federal inspectors cited Lindengrove Menomonee Falls for immediate jeopardy violations during a March inspection, finding the facility endangered residents through systematic failures in wound care and accident prevention.
R350 arrived at the facility with existing pressure injuries — a full-thickness stage 3 ulcer on the right buttock and a stage 1 injury on the left heel. Hospital discharge instructions required registered nurses to assess the wound and change dressings three times weekly. The facility's own policy mandated comprehensive skin assessments within 14 days of admission.
Nobody performed a skin assessment on R350 from August 28 through September 28.
The resident scored 4 on cognitive testing, indicating severe impairment, and required substantial assistance for bed mobility and transfers. Despite being classified at risk for pressure injuries, the facility's wound nurse told inspectors during an interview that R350 "likes to stay in bed" and is "dependent for bed mobility."
When inspectors asked about the missing month of assessments, staff provided no explanation.
The facility's fall prevention system collapsed across multiple residents. Six people experienced repeated falls without proper investigation or implementation of ordered safety measures.
R12, a hospice patient with vascular dementia, fell three times between September and December 2024. Each incident revealed the same pattern: staff conducted minimal investigations and failed to ensure prescribed interventions were in place.
On December 11, staff found R12 on the floor with a bump on her head. The investigation noted the floor mat wasn't positioned correctly and the bed wasn't in its lowest position — both required safety measures. No one documented whether the prescribed body pillow was in place during the fall.
Inspectors observed the failures firsthand. On February 11, they watched a nursing assistant care for R12, raising the bed height and removing the floor mat without replacing either safety measure before leaving the room. The body pillow remained propped against a recliner in the corner rather than on the bed as ordered.
When asked about the body pillow, the assistant said it was used "at night." The care plan required it whenever R12 was in bed.
R23, another resident receiving hospice care, fell four times between November 2024 and January 2025. Investigation records contained conflicting information about staff presence during incidents, and no one verified whether prescribed interventions like gait belts were being used during transfers.
Inspectors watched staff transfer R23 from bed to wheelchair without the required gait belt, despite the device hanging on the back of the door. When questioned, the nursing assistant claimed hospice services had removed the gait belt requirement — contradicting the active care plan.
The facility's Director of Nursing told inspectors staff were supposed to investigate falls by interviewing witnesses and determining what residents were doing before incidents occurred. "Sometimes it's difficult to get a hold of them," she said about following up with nursing assistants.
Multiple medication and treatment failures compounded resident safety risks. Two residents with urinary catheters went months without required output monitoring. R23's catheter output wasn't documented from admission in November through February 16, despite physician orders requiring monitoring three times daily.
R23's oxygen tubing, dated December 7, wasn't changed until inspectors pointed out the violation in February — despite orders requiring weekly replacement.
The facility's infection control program crumbled during two disease outbreaks. The Assistant Director of Nursing, who also served as infection preventionist, told inspectors she didn't document outbreak timelines or analyze what could be done better "because I was not aware I had to."
During COVID and influenza outbreaks affecting multiple residents and staff, the facility tracked only basic symptom information without comprehensive intervention analysis or improvement planning.
Staffing records revealed registered nurses were absent from the facility for consecutive eight-hour periods on dozens of days between July 2024 and February 2025, violating federal requirements. The scheduler responsible for nursing assignments wasn't aware that designating a charge nurse for each shift was required.
Kitchen operations violated basic food safety standards. Staff worked without proper hair restraints while preparing meals. The dishwashing machine's sanitization wasn't monitored or documented for months at a time, with no backup system to ensure dishes were properly cleaned.
Dietary staff delivered uncovered food items to resident rooms, carrying trays down hallways without protection from contamination. When the Regional Food Service Director was informed of the violations, she acknowledged "someone is not doing their job."
The facility's water management program existed largely in the maintenance manager's memory. Required temperature monitoring, flushing schedules, and system inspections weren't documented. The manager told inspectors he kept track of interventions "in my head" and would "call a plumber if temperatures are outside the proper range" — with no records of whether this ever occurred.
An activity room toilet remained out of service for a week with stagnant water in the lines while the manager waited for repair parts.
Residents weren't receiving food according to their documented preferences. R196 repeatedly received oatmeal despite meal tickets stating "dislikes oatmeal" and specifying cold cereal daily. R197 got eggs for breakfast when meal tickets indicated egg dislikes.
The facility's antibiotic stewardship program failed basic oversight. R23 received a seven-day course of antibiotics for a urinary tract infection without meeting the facility's own criteria for infection treatment. The infection preventionist acknowledged the resident "did not" meet McGeer's criteria — the facility's standard for antibiotic use.
R7 received the blood thinner warfarin for months without any documented monitoring for adverse effects, despite care plans requiring staff to watch for medication side effects every shift.
During the inspection's final days, administrators promised improvements but provided little explanation for the systematic failures. The facility's plan of correction, submitted after the inspection, outlined new policies and training programs.
The violations affected all 49 residents in the building, with immediate jeopardy citations indicating the most serious level of harm under federal nursing home regulations.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Lindengrove Menomonee Falls in MENOMONEE FALLS, WI was cited for immediate jeopardy violations during a health inspection on March 3, 2025.
R350 arrived at the facility with existing pressure injuries — a full-thickness stage 3 ulcer on the right buttock and a stage 1 injury on the left heel.
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.