Lindengrove Menomonee Falls: Care Plan Failures - WI
The resident, identified in inspection records as R350, was admitted to the facility with skin integrity problems. That was the reason for the admission. The hospital that discharged R350 had already documented specific interventions, including an air mattress, heel boots, a turning and repositioning schedule, and a wheelchair cushion. None of those interventions made it into R350's baseline care plan.
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See the Derila PillowThe baseline care plan is supposed to be completed within 48 hours of a resident's arrival. It is the first written record of what a facility intends to do for a new resident, and it is supposed to be signed and reviewed with the resident's representative. For R350, that review never happened with the power of attorney within the required window. The plan was not completed. It was not signed. It was not reviewed.
More specifically, the section of the care plan form dedicated to skin integrity, the very health condition that brought R350 through the door, was left blank.
The Director of Nursing, identified as DON-B, confirmed to inspectors on February 17, 2025, that yes, the air mattress, heel boots, turning and repositioning schedule, and wheelchair cushion should have been included in the baseline care plan. The Nursing Home Administrator, identified as NHA-A, was present for that conversation. No additional information was provided by either of them.
The inspection was conducted March 3, 2025, by the Wisconsin Department of Health Services on behalf of the Centers for Medicare and Medicaid Services. Inspectors classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected.
That classification, minimal harm, describes the regulatory finding. It does not describe what the first 48 hours looked like for a person admitted with open or compromised skin, whose care team had no written plan specifying the pressure-relieving mattress they were supposed to be lying on, the boots designed to keep their heels from developing new wounds, or how often staff were supposed to turn them to prevent pressure from building in one place.
Skin integrity failures are among the most common and most serious problems inspectors find in nursing homes. Pressure injuries, once they develop, can progress rapidly. A wound that begins as reddened skin can become an open sore, then a deep wound reaching muscle or bone, within days. The interventions listed in R350's hospital discharge summary, the air mattress, the heel protection, the repositioning schedule, exist precisely because that progression is predictable and preventable.
The hospital sending R350 to Lindengrove had already done the work of identifying what that person needed. The discharge summary spelled it out. The facility's own care plan form had a section for skin integrity. What was missing was someone filling it in, and someone reviewing it with R350's family representative before 48 hours had passed.
DON-B, when asked, said yes, those things should have been there. That was the full extent of the facility's response documented in the inspection record.
R350's power of attorney, whoever was responsible for that resident and presumably waiting to understand how their family member would be cared for, did not receive that conversation within the required window. Whether they were ever told what interventions the hospital had recommended, or whether those interventions were actually implemented in the days after admission, the inspection record does not say.
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.
The resident, identified in inspection records as R350, was admitted to the facility with skin integrity problems.
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.