Lindengrove Menomonee Falls: Delayed Fracture Report - WI
The resident, known in inspection records as R2, suffered from spastic hemiplegia affecting their right dominant side and quadriplegia. On August 7, Licensed Practical Nurse 1 documented that the resident "complained of right ankle pain and requested to be sent out to the hospital."
The hospital visit revealed more than anyone expected.
R2 returned that evening with a prescription for oxycodone and a diagnosis of "closed fracture of the right ankle." But the x-ray report contained a troubling detail: the fracture was of "undetermined age."
That phrase should have triggered immediate action. Federal regulations require nursing homes to report injuries of unknown origin within 24 hours to state authorities. The clock started ticking the moment R2 returned from the hospital on August 7.
Instead, Lindengrove Menomonee Falls waited.
Licensed Practical Nurse 1 told inspectors she reported the fracture to the Director of Nursing after R2 returned from the hospital. The Director of Nursing confirmed she received the report timely and made the Administrator aware.
"The DON stated she believed it was a reportable event, but the Interim Administrator was unsure and wanted to get some additional information," inspectors wrote. "She stated that was why it was reported late."
The facility finally submitted its Misconduct Incident Report to the State Survey Agency on August 12 at 12:29 PM. Five days after the injury was first identified.
The report acknowledged the timeline: "Patient c/o sore ankle and wanted to go to the ER patient's POA was called and agreed to have patient sent out to the hospital. Patient was sent out on Thursday 8/7/25. Patient returned from ER later that evening with closed right ankle fracture. X-ray report reads fracture age undetermined per x-ray report."
R2's cognitive status made the delay particularly concerning. The resident scored eight out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. With spastic hemiplegia affecting their dominant side and quadriplegia, R2 was among the facility's most vulnerable residents.
The inspection revealed this wasn't an isolated case of confusion about reporting requirements. Federal inspectors found the facility "failed to report an injury of unknown origin within required timeframes" and noted that such failures "place all residents at risk of abuse."
The phrase "injury of unknown origin" carries specific regulatory weight in nursing homes. It signals that staff cannot account for how a resident sustained an injury, triggering mandatory reporting protocols designed to protect vulnerable residents from potential abuse or neglect.
When R2 complained of ankle pain on August 7, staff appropriately contacted the resident's Power of Attorney and arranged hospital transport. The hospital's diagnostic process followed proper protocols, including x-rays that revealed the closed fracture.
But the x-ray report's conclusion that the fracture age was "undetermined" should have immediately classified this as an injury of unknown origin. No one at Lindengrove could explain when or how R2's ankle was broken.
The five-day delay occurred despite clear knowledge among key staff that reporting was required. The Director of Nursing told inspectors she "believed it was a reportable event" from the beginning. The Licensed Practical Nurse who first documented R2's complaint understood the need to escalate the information through proper channels.
The breakdown happened at the administrative level, where the Interim Administrator's uncertainty overrode established reporting protocols. Rather than err on the side of resident protection by reporting immediately, facility leadership chose to seek "additional information" while days passed.
Federal inspectors conducted their review as part of a complaint investigation on August 19, examining three residents' cases for potential abuse. R2 was the only resident among the three whose injury reporting violated federal requirements, but inspectors noted the failure put the facility's entire resident population at risk.
The inspection report doesn't detail what "additional information" the Interim Administrator sought during those five days, or what ultimately convinced facility leadership to file the required report. The delay suggests confusion about fundamental resident protection requirements at the administrative level.
R2's case illustrates how reporting delays can compound risks for vulnerable residents. With moderate cognitive impairment and severe physical limitations, R2 couldn't advocate for proper investigation of their injury. The resident's ability to communicate was further compromised by their dominant-side hemiplegia.
The hospital's finding of an "undetermined age" fracture meant medical professionals couldn't establish when the injury occurred. This uncertainty should have prompted immediate investigation by state authorities trained to examine unexplained injuries in nursing home settings.
Instead, R2's case sat unreported for five days while administrators deliberated. During that period, any potential evidence related to the injury's cause could have deteriorated. Staff members who might have witnessed relevant events could have forgotten crucial details. Security footage, if it existed, might have been overwritten.
The facility's own incident report, filed five days late, provided no additional insight into how R2 sustained the fracture. The summary simply repeated the basic timeline: complaint of pain, hospital visit, diagnosis of closed fracture with undetermined age.
Federal inspectors classified this as a violation causing "minimal harm or potential for actual harm" affecting "few" residents. But the citation acknowledged broader implications, noting that reporting failures "place all residents at risk of abuse."
The inspection occurred during a complaint investigation, suggesting someone outside the facility raised concerns about resident care that prompted state scrutiny. The timing of the inspection, just one week after the delayed report was finally submitted, indicates state authorities moved quickly once they became aware of potential problems.
R2 returned from the hospital with pain medication but no clear answers about their injury. The resident who asked to go to the hospital because of ankle pain became the subject of a federal investigation into their facility's failure to protect vulnerable residents through proper reporting.
The case ended with R2 carrying both a broken ankle of unknown origin and the knowledge that their nursing home waited five days to tell state authorities about it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lindengrove Menomonee Falls from 2025-08-19 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 violations during a health inspection on August 19, 2025.
The resident, known in inspection records as R2, suffered from spastic hemiplegia affecting their right dominant side and quadriplegia.
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.