Lindengrove Menomonee Falls: Nursing Oversight Failures - WI
There was no registered nurse in the building.
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See the Derila PillowThe resident, identified in inspection records as R297, was transferred to the hospital on August 13, 2024. What inspectors found when they reviewed his records and interviewed staff raised questions that the facility's own Director of Nursing could not answer months later.
The nursing student, identified as Nursing Student-CCC, told inspectors she remembered "bits and pieces" of what happened that night. She wasn't sure who had called the advanced practice nurse. She couldn't recall how she learned R297 wasn't urinating, only that "she thinks R297 told her he wasn't able to go." She believed the LPN, identified as LPN-H, had communicated with the Director of Nursing, but wasn't certain. She didn't think there was an RN in the building.
LPN-H, for her part, told inspectors this was the first time she had ever sent a patient to the hospital.
That detail, offered without elaboration, sits at the center of what inspectors documented: a resident's medical decline managed by someone fresh out of school, assisted by a student, with no licensed RN on the floor to conduct an assessment or supervise the clinical decisions being made.
Nursing Student-CCC described LPN-H to the inspector as "kind of doing everything" because she had just graduated and was new. The nursing student said she was working under LPN-H and had created an order for a urinalysis. She believed LPN-H had called the advanced practice nurse, identified as APNP-FFF, but wasn't sure whether it was a call or a text.
The care gaps didn't begin on August 13. Inspectors found a note from APNP-FFF dated July 22, 2024, documenting two dressings applied to R297. When the surveyor asked the Director of Nursing, identified as DON-B, whether there was an assessment on file to accompany those dressings, DON-B reviewed the record and confirmed there wasn't one.
"There should be," DON-B told the surveyor.
DON-B described R297 as a pleasant man, diabetic, without many complaints. She knew he scratched himself and that cream had been ordered. She said nothing else had been ordered beyond that. She had no memory of being contacted when he was transferred to the hospital on August 13.
The surveyor asked DON-B who the on-call RN had been the evening R297 was sent out. DON-B said she didn't know. The surveyor asked her to look it up and provide the name.
She never did.
The inspection report notes simply: "DON-B did not provide Surveyor with the name of the on call RN. No additional information was provided."
DON-B told the surveyor that the standard expectation when an LPN identifies a change of condition is to notify the medical doctor for further orders, and to let management know so that an RN can assess the resident. Whether that happened for R297 on August 13 remained unresolved. DON-B said she didn't recall being called. She didn't know who was on call. The LPN said she communicated with the DON. The nursing student thought she did too, but wasn't sure.
What the record does show is a man who wasn't urinating, who wasn't acting like himself, being evaluated by the least experienced staff on the floor, with no documented RN assessment, and a hospital transfer that LPN-H had never had to make before in her career.
R297's condition after that transfer is not described in the inspection report. What happened to him, and what the hospital found, is not in the record inspectors reviewed.
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 14, 2026 · Our methodology
Lindengrove Menomonee Falls in MENOMONEE FALLS, WI was cited for violations during a health inspection on March 3, 2025.
There was no registered nurse in the building.
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.