Lindengrove New Berlin: Fall Injury After No Safety Plan - WI
The fall happened on July 7, 2025, at Lindengrove New Berlin. The resident had been left alone long enough to fall, go undiscovered, and require an ambulance.
She told staff what happened. "I was trying to pick up my hearing aide and I was sliding, then I fell." She said she hadn't struck her head, but the assessment told a different story: a laceration on her right forehead and bruising at the corner of her right eye. EMS transported her to a hospital for further evaluation.
The resident's medical history was not a secret. Her chart listed hemiplegia and hemiparesis following a stroke, affecting the right dominant side. Generalized muscle weakness. Polyarthritis. Lumbar spondylosis. A shoulder and upper arm strain on the right side. Type 2 diabetes. Vitamin D deficiency. Unsteadiness on her feet. And, listed explicitly among her diagnoses: repeated falls.
This was not a resident whose fall risk was unknown or ambiguous. The risk was documented, named, coded, and sitting in her record.
The interdisciplinary team reviewed the incident and concluded she had slipped from her wheelchair while reaching down for the hearing aid. Their response was to update her care plan so that she would eat her meals near the nurses' station, per her own preference. That was the intervention. Move her closer to the desk.
Federal inspectors cited the facility under F0689, which covers the obligation to ensure residents receive adequate supervision and assistive devices to prevent accidents. The citation was tagged at the level of actual harm, meaning inspectors determined the resident had already been hurt, not that she might be someday.
What the investigation did not document was what supervision, if any, had been in place before she fell. The fall was unwitnessed. That fact alone — that no staff member saw a woman with paralysis, a stroke history, and a documented pattern of falling attempt to lean out of her wheelchair in a dining room — is the center of this citation.
The care plan update came after the fall. What the record does not show is what the care plan said before it.
The facility's fall investigation, prepared by the licensed practical nurse and unit manager, summarized the incident and the steps taken: vital signs, neurological checks, EMS contact, family and staff notifications. All appropriate responses to a fall that had already happened. The investigation identified the mechanism clearly. It did not identify a gap in supervision or a failure in prior planning as contributing factors, at least not in the portion of the report reviewed by the surveyor.
The resident was taken to the hospital by ambulance after dinner on a Monday in July. Her power of attorney was notified. The on-call nurse practitioner was notified. The unit manager was notified.
The housekeeper who found her on the floor was not quoted in the investigation summary.
After she returned, the facility's answer was a seat closer to the nurses' station. Whether anyone would be watching from that station the next time she dropped something and reached for it, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lindengrove New Berlin from 2025-09-08 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 30, 2026 · Our methodology
Lindengrove New Berlin in NEW BERLIN, WI was cited for violations during a health inspection on September 8, 2025.
The fall happened on July 7, 2025, at Lindengrove New Berlin.
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.