Lindengrove Menomonee Falls: Pressure Wound Failures - WI
The resident, identified in inspection records as R350, was admitted in early February 2025 carrying diagnoses that included Alzheimer's disease, dementia, and two active pressure injuries: a stage 3 wound on her right buttock and a stage 1 wound on her left heel. A hospital wound specialist had documented the buttock wound just days before her admission. It measured 8 centimeters by 8 centimeters, roughly the size of a fist, and penetrated through the full thickness of the skin.
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The hospital's discharge summary, dated February 6, 2025, spelled out the wound care protocol in precise, step-by-step terms. Staff were to cleanse the buttock wound with Puracyn Plus, soaking gauze for five minutes, pat it dry, apply a barrier cream to the surrounding skin, layer a wound contact dressing over the injury, and cover everything with a sacral Mepilex dressing. A registered nurse was to assess the wound and change the dressing three times a week. The heel required its own separate protocol.
R350 could not advocate for herself. Her Brief Interview for Mental Status score, recorded in her admission assessment, was a 4, placing her in the severely cognitively impaired range. She required substantial to maximum assistance just to move in bed. She could not independently transfer at all. Her power of attorney had been activated.
The Braden Scale assessment completed on the same day as her discharge, February 6, confirmed what anyone looking at her medical history already knew: she was at risk for pressure injuries. She had arrived with two of them already.
Inspectors cited the facility at the Immediate Jeopardy level, the most serious classification CMS assigns, meaning the failure created a situation likely to cause serious injury, harm, or death if not corrected immediately.
The facility submitted a plan of correction. According to inspection records, Lindengrove reviewed and updated its standard skin protocol on February 17, reviewed its skin policy and procedure, discussed the citation with its medical director, and committed to having the director of nursing or a designee audit five residents weekly for skin care compliance. Results were to go to the facility's Quality Assurance and Performance Improvement committee.
Inspectors determined those steps reduced the violation from Immediate Jeopardy, but they did not close it out entirely. The deficient practice continued, downgraded to a scope and severity of D, meaning inspectors found it isolated but still carrying the potential for more than minimal harm.
A stage 3 pressure wound is not a surface problem. It has broken through the outer layers of skin and into the tissue beneath. An 8-by-8-centimeter wound of that depth requires consistent, correctly executed care to prevent it from worsening, becoming infected, or both. The hospital's discharge team understood this. They did not send R350 to Lindengrove with a general suggestion to keep the wound clean. They sent her with a protocol.
R350's admission minimum data set assessment was still in the process of being completed when inspectors reviewed her records. She had been at the facility only weeks when the inspection took place on March 3, 2025.
The inspection record does not say whether her wounds healed, worsened, or became infected during her time at Lindengrove. It does not say whether her power of attorney was notified about the lapse in care. What it says is that a woman who could not move herself, could not speak for her own medical needs, and arrived with wounds that required precise nursing intervention three times a week did not receive the care her discharging hospital had prescribed.
Her name is not in the record. Her outcome is not in the record. What remains is the wound measurement: 8 by 8 centimeters, stage 3, right buttock, documented by a specialist who believed someone else would follow through.
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.
A hospital wound specialist had documented the buttock wound just days before her admission.
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.