The resident, identified as R2 in the November inspection report, was prescribed Mirtazapine 15 mg for depression with orders to take 1.5 tablets at bedtime starting August 6. The medication was supposed to help treat depression alongside the resident's other conditions, which included a right femur fracture, atrial fibrillation, chronic kidney disease, type 2 diabetes, and hypothyroidism.
Staff at Lindengrove Menomonee Falls marked the resident's medication administration record with check marks indicating the antidepressant was given on multiple dates between September 5 and September 14. But pharmacy records tell a different story.
The facility's pharmacy partner confirmed they sent a 30-day supply of Mirtazapine on August 6 that lasted through September 3. No additional medication was sent until September 15 — creating an 11-day gap when the drug wasn't available.
During that period, staff documented at least three specific dates when the medication wasn't given: September 9, 10, and 13. Those entries were marked with a code indicating "other/see progress notes," but no explanation appeared in the resident's progress notes explaining why the doses were skipped.
The facility's own medication policy requires staff to search the medication cart, medication room, and other areas if a prescribed drug can't be located. If the medication still can't be found, staff are supposed to contact the pharmacy or remove doses from the emergency supply.
Pharmacy Manager-T reviewed the facility's emergency medication system and found no Mirtazapine had been removed for R2 between September 5 and September 15. The emergency supply contained the medication, but staff never accessed it.
"The medication does not require a prescription, the facility only needs to remove the reorder label and fax the pharmacy for refill," Pharmacy Manager-T told inspectors.
Instead, staff continued marking the medication record as if doses were being administered. The pharmacy partner confirmed they sent 45 tablets on August 6 and another 45 tablets on September 15, with 38 tablets returned when the resident was discharged.
The resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. This means R2 would have been aware of receiving or not receiving the prescribed antidepressant medication during the treatment gap.
Federal regulations require nursing homes to provide routine and emergency drugs to meet each resident's needs, including procedures that ensure accurate acquiring, receiving, dispensing, and administering of all medications. The facility's policy states that medications must be administered "as prescribed in accordance with good nursing principles and practices."
The inspection found that Lindengrove Menomonee Falls failed to provide pharmaceutical services to meet residents' needs for at least one of four residents reviewed during the complaint investigation.
When inspectors raised concerns about the missing Mirtazapine doses with Nursing Home Administrator-A on November 4, no additional information was provided to explain the medication gap or the falsified administration records.
The resident was admitted to the facility following a right femur fracture and was dealing with multiple serious health conditions including stage 4 chronic kidney disease. Depression treatment would have been particularly important for someone recovering from a major injury while managing multiple chronic illnesses.
The facility's medication distribution system, which is supposed to ensure safe administration without unnecessary interruptions, failed to prevent the resident from going without prescribed psychiatric medication for nearly two weeks. Staff documented giving medication that wasn't available and made no apparent effort to obtain it from the emergency supply that contained the drug.
The inspection classified the violation as causing minimal harm or potential for actual harm to few residents. But for R2, the gap in antidepressant treatment came during recovery from a serious fracture while managing multiple chronic conditions that could have been worsened by untreated depression.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lindengrove Menomonee Falls from 2025-11-11 including all violations, facility responses, and corrective action plans.