Lindengrove Menomonee Falls: Fracture Report Filed Late - WI
That delay is the finding at the center of a complaint inspection completed August 19 at Lindengrove Menomonee Falls, a nursing facility on Town Hall Road in this Milwaukee suburb. Federal inspectors cited the facility for failing to report an injury of unknown origin within required timeframes to the Wisconsin State Survey Agency.
The resident at the center of the finding, identified in inspection records only as Resident 2, had been living at the facility since an admission date redacted from public records. The diagnoses on file included spastic hemiplegia affecting the right dominant side and quadriplegia. A cognitive assessment completed in July 2025 placed the resident's Brief Interview for Mental Status score at eight out of fifteen, a range that indicates moderate cognitive impairment. The resident could communicate a complaint, but would have had limited ability to track what happened next or advocate for a formal investigation.
On the afternoon of August 7, the resident told staff the right ankle hurt and asked to go to the hospital. A licensed practical nurse documented the complaint and the transfer. Later that evening, the resident returned with a prescription for oxycodone and a new diagnosis: closed fracture of the right ankle. The x-ray report, according to the facility's own misconduct incident report filed five days later, described the fracture age as undetermined.
That phrase, fracture age undetermined, is what triggers mandatory reporting. When a resident sustains an injury and the cause cannot be established, it is classified as an injury of unknown origin. The concern is straightforward: an unexplained fracture in a cognitively impaired, physically dependent resident could be the result of abuse or neglect. The reporting requirement exists so that state investigators can look into it quickly, while evidence and memories are still fresh.
The facility submitted its misconduct incident report to the state on August 12 at 12:29 in the afternoon. That was five days after the resident returned from the hospital. The report itself acknowledged the timeline plainly, noting the patient had been sent out on Thursday, August 7, and returned that evening with a closed right ankle fracture.
When inspectors interviewed the licensed practical nurse who had cared for the resident on August 19, she said she had reported the fracture to the Director of Nursing after the resident came back from the hospital. She said she told the director what the hospital found.
The Director of Nursing told inspectors she received that report in a timely way and made sure the administrator was aware. Then she described what happened next. She said she believed the fracture was a reportable event. The interim administrator, she said, was not sure, and wanted to gather additional information before filing. That process took five days.
The inspection report does not say what additional information the interim administrator was seeking, or whether any investigation into the fracture's cause was underway during those five days. It does not say whether anyone attempted to reconstruct how a resident with quadriplegia and hemiplegia sustained a fracture of undetermined age to the ankle of the side affected by hemiplegia. It does not say whether staff reviewed recent care records, transfer logs, or repositioning notes during the delay.
What it says is that the Director of Nursing knew, the administrator knew, and the report was filed five days late because one of them wasn't sure it needed to be filed at all.
The inspection cited this as a deficiency with a level of harm characterized as minimal harm or potential for actual harm, the lower end of the federal harm scale. Inspectors noted the failure to report injuries of unknown origin on time places all residents at risk of abuse, not only the resident whose fracture prompted the complaint.
That framing reflects how these reporting requirements actually function. A nursing home that delays or skips mandatory reporting of unexplained injuries isn't just making a paperwork error. It is narrowing the window in which an outside investigator can determine what happened. Staff memories fade. Bruising resolves. The sequence of events that led to a fracture becomes harder to reconstruct with each passing day. Five days is not a trivial gap.
Resident 2's situation made that gap particularly significant. Quadriplegia involves paralysis affecting all four limbs. Spastic hemiplegia affects one side of the body with both weakness and increased muscle tone. A resident with that combination is among the most physically dependent people in a nursing home, relying on staff for repositioning, transfers, bathing, dressing, and virtually every other physical need. The fracture was to the right ankle, the same side affected by the hemiplegia. The x-ray could not determine when it happened.
The facility did eventually file the report. The interim administrator's hesitation did not result in the injury going unreported entirely. But the five-day delay meant that whatever investigation the state might conduct began nearly a week after the fracture was identified, and an unknown period after it actually occurred.
The inspection covered three residents reviewed for abuse out of a total sample of six. The deficiency was cited for one of the three. The report does not describe findings related to the other residents in the abuse review sample.
Lindengrove Menomonee Falls is one of several facilities operating under the Lindengrove name in Wisconsin. The inspection was triggered by a complaint, meaning someone, whether a resident, family member, staff member, or other party, contacted authorities before inspectors arrived. The report does not identify who filed the complaint or what it alleged.
As of the inspection date, the facility had not yet submitted a plan of correction. Under federal rules, plans of correction for nursing homes become publicly available fourteen days after they are provided to the facility.
Resident 2 returned from the hospital with a broken bone of unknown age, a prescription for oxycodone, and a moderate cognitive impairment that made self-advocacy difficult. The nursing home took five days to tell the state it had happened, and the reason given was that the interim administrator needed more time to decide if the rules applied.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Lindengrove Menomonee Falls in MENOMONEE FALLS, WI was cited for violations during a health inspection on August 19, 2025.
Federal inspectors cited the facility for failing to report an injury of unknown origin within required timeframes to the Wisconsin State Survey Agency.
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.