Lindengrove Menomonee Falls: Fracture Investigation Flaws - WI
The 83-year-old woman, identified in state records as Resident 2, complained of right ankle pain to Licensed Practical Nurse 4 and Certified Nursing Assistant 3 during their second shift on July 6. She requested to be sent to the hospital.
More than a month later, she got her wish.
On August 7, LPN 1 documented that the resident "complained of right ankle pain and requested to be sent out to the hospital." The same nurse wrote a second note that day: "resident returned from hospital with order for oxycodone diagnosis closed fracture of the right ankle."
The resident had been living at Lindengrove Menomonee Falls since her admission with diagnoses including spastic hemiplegia affecting her right dominant side and quadriplegia. Her July quarterly assessment showed she scored eight out of 15 on a mental status exam, indicating moderate cognitive impairment.
During the facility's investigation into the fracture, the resident told staff that her ankle was hurt during a manual transfer when employees moved her by themselves without using a Hoyer lift or getting help from another worker.
The investigation concluded the most likely cause of the fracture was staff improperly transferring the resident during care. But investigators couldn't verify what happened.
They never asked the two staff members who first heard her complaints.
State inspectors discovered the oversight during their August review. LPN 4 and CNA 3 told investigators they remembered the resident complaining of ankle pain on July 6 during their shift. Both had direct knowledge of her pain complaints, but neither was interviewed during the facility's investigation or asked to write a statement about what they observed.
The facility's self-report form, dated August 15 at 10:69 PM, revealed that not all staff involved with the resident's care prior to the fracture diagnosis were interviewed for knowledge related to the incident.
During an interview on August 19 at 2:59 PM, the Director of Nursing admitted she was unaware that LPN 4 and CNA 3 had not been interviewed. She agreed that they should have been questioned and their statements should have been included in the investigation.
The gap in the investigation left crucial questions unanswered. If the resident was complaining of ankle pain more than a month before her hospital visit, why wasn't she examined sooner? What did the staff members who first heard her complaints observe about her condition? Did they witness the transfer she claimed caused her injury?
The resident's medical complexity made proper handling essential. Quadriplegia affects all four limbs, while her spastic hemiplegia caused muscle stiffness and involuntary contractions on her right side. Moving someone with these conditions requires careful technique and often mechanical assistance or multiple staff members.
Her cognitive impairment, while moderate, didn't prevent her from communicating her pain or requesting hospital care. She was clear about what hurt and how it happened.
The facility's investigation protocol requires interviewing all staff with relevant knowledge when a resident sustains an injury of unknown origin. The state inspection found this didn't happen, despite the resident's specific account of being improperly transferred.
State inspectors classified the violation as causing minimal harm or potential for actual harm, but noted that failure to thoroughly investigate injuries of unknown origin places residents at risk of continued abuse.
The inspection focused on three residents reviewed for potential abuse out of a total sample of six. Only one case revealed investigative failures.
Federal regulations require nursing homes to immediately investigate any allegation of abuse, neglect, exploitation, or mistreatment. The investigation must include interviews with all relevant staff and documentation of findings.
When residents can't advocate for themselves due to physical or cognitive limitations, thorough investigations become their primary protection against repeated harm. Missing key witness interviews undermines that safeguard.
The resident's account suggested a preventable injury caused by understaffing or inadequate training. Manual transfers of residents with quadriplegia typically require two people or mechanical assistance. Attempting such transfers alone violates standard safety protocols.
Her month-long wait for medical attention raises additional concerns about pain management and medical oversight. Residents with limited mobility can't easily demonstrate their discomfort through movement or positioning changes, making staff observation and response critical.
The facility's admission that key staff weren't interviewed suggests systemic problems with investigation procedures. If supervisors don't know which employees have relevant information, how can they ensure complete investigations?
The Director of Nursing's surprise at learning about the oversight indicates a breakdown in communication between direct care staff and management. LPN 4 and CNA 3 had firsthand knowledge of the resident's complaints but apparently weren't identified as necessary witnesses.
The state's finding that the investigation "could not be verified" reflects the consequences of incomplete fact-gathering. Without statements from all relevant staff, investigators couldn't determine exactly what happened or whether proper procedures were followed.
The resident remains at the facility with her closed ankle fracture and ongoing need for careful handling during transfers. Her experience illustrates how investigative shortcuts can leave vulnerable residents without answers about their injuries or assurance that similar incidents will be prevented.
The inspection occurred following a complaint, suggesting someone reported concerns about the facility's handling of the incident. State inspectors reviewed records, interviewed staff, and examined facility policies before concluding that the investigation fell short of required standards.
For a resident who told staff exactly how she was injured and which employees were involved, the facility's failure to interview key witnesses represents a missed opportunity to understand what went wrong and prevent similar injuries to other vulnerable residents.
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.
She requested to be sent to the hospital.
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.