Inspection Report

Lindengrove New Berlin: Physician Not Notified of Rash - WI

June 30, 2026

New Berlin, WI

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The inspection, completed September 8, 2025, centered on a single resident, identified in the report as R2. On July 24, a nurse completed what the facility calls a Skin Only Evaluation and recorded that R2 had a rash. The physician was not contacted. No treatment order was sought. The documentation sat in the chart.

When the inspector surfaced the July 24 evaluation and asked Nurse Supervisor-O why the physician had never been notified, the supervisor said she wanted to look into it. She followed up two days later, on September 4, and said she had not known about the rash and could not explain why the doctor wasn't called.

The Director of Nursing, identified as DON-B, was interviewed the morning of September 8. She said she would look into it. Less than an hour later, she came back with an explanation: the nurse who charted the rash said it was mild redness, that she had cleaned the area and applied barrier cream, and that for mild redness the facility would not expect a nurse to contact the physician.

The inspector was not satisfied with that answer, and for a specific reason. The July 24 Skin Only Evaluation used the word "rash." The nurse's own late-entry progress note, written on September 8, the same morning as the interview, also used the word "rash." The note read that the resident had a mild rash in the abdominal folds, that she was cleaned and dried well, and that barrier cream was applied.

A rash and mild redness are not the same thing. The inspector made that point directly to DON-B at 10:58 that morning. No additional explanation was provided.

What the record shows is a nurse who found something, wrote it down twice using the word "rash," and still framed it afterward as too minor to warrant a phone call. The supervisor above her didn't know. The director of nursing didn't know. The physician, whose job it is to evaluate and order treatment for a resident's skin condition, was never given the chance to weigh in.

The deficiency was cited at a harm level of minimal harm or potential for actual harm, meaning inspectors did not find that R2 suffered a serious injury as a result. But the gap between what was found and what was done about it, and the fact that a late-entry progress note was added to the chart on the same day the inspector raised the concern, six weeks after the original finding, is its own kind of record.

The late entry note did not change what had already not happened. The physician still was not contacted in July. No one at the facility could say why.

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

Editorial Standards

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

Quick Answer

Lindengrove New Berlin in NEW BERLIN, WI was cited for violations during a health inspection on September 8, 2025.

The inspection, completed September 8, 2025, centered on a single resident, identified in the report as R2.

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.

Frequently Asked Questions

What happened at Lindengrove New Berlin?

The inspection, completed September 8, 2025, centered on a single resident, identified in the report as R2.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in NEW BERLIN, WI, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Lindengrove New Berlin or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525064.

Has this facility had violations before?

To check Lindengrove New Berlin's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.