Federal inspectors found Lindengrove Menomonee Falls consistently delivered 3.5 liters of oxygen to the resident instead of the 2 liters ordered by physicians. The overdose occurred weeks after the same resident's oxygen had disconnected at tube connectors, causing hypoxia that required ambulance transport on October 16.
The November inspection revealed staff had implemented no meaningful changes despite the previous emergency.
Inspectors observed the resident sitting in a wheelchair receiving oxygen through a nasal cannula on November 3 at 9:18 a.m. The oxygen concentrator was set at 3.5 liters. The resident's physician orders specified 2 liters.
When a certified nursing assistant prepared to take the resident out of the room, she switched the oxygen source to a small portable tank correctly set at 2 liters. But when the resident returned to the room later that day, staff reconnected the oxygen tubing to the concentrator still delivering the excessive dose.
The pattern continued the next morning. At 7:06 a.m. on November 4, inspectors found the resident again receiving 3.5 liters from the concentrator. The oxygen tubing consisted of two separate tubes connected together rather than one continuous line.
Over the next two hours, inspectors documented the resident remained on the incorrect oxygen setting. At 8:48 a.m., a licensed practical nurse delivered breakfast to the resident but failed to adjust the concentrator to the prescribed 2 liters.
The resident continued eating breakfast at 9:26 a.m. while receiving the overdose.
When inspectors questioned Licensed Practical Nurse N at 9:35 a.m. about the resident's oxygen prescription, the nurse incorrectly stated it was "2 to 3 liters." After being informed the physician orders specified 2 liters, the nurse accompanied inspectors to the resident's room and finally lowered the concentrator to the correct setting.
The excessive oxygen delivery occurred against the backdrop of the facility's failure to implement safety measures following the October emergency. Registered Nurse and Nurse Supervisor O told inspectors she learned "after the fact" that the resident's oxygen had been disconnected during the incident that required ambulance transport.
"She was informed after the fact R1's oxygen was not connected," the inspection report states. The nurse supervisor said she "did not notice" the disconnection when she was in the resident's room and "doesn't remember who came and told her that the ambulance found the oxygen disconnected at the connectors."
To prevent future disconnections, facility staff decided to use one continuous oxygen tube from the nasal cannula to the concentrator instead of connectors that could separate.
Yet weeks later, inspectors found the resident still receiving oxygen through two connected tubes. When the nurse supervisor accompanied inspectors to the resident's room on November 4, they showed her the continuing use of connected tubing rather than the single continuous tube the facility had identified as necessary for safety.
Inspectors noted the facility had failed to update the resident's care plans for oxygen therapy or shortness of breath to include the intervention of continuous tubing.
The resident's medical conditions include shortness of breath, emphysema, and chronic obstructive pulmonary disease, making proper oxygen management critical for health and safety.
The violations occurred during a complaint investigation at the 120-bed facility operated by Lindengrove. Federal regulators cited the nursing home for failing to ensure residents received treatment and care in accordance with professional standards of practice.
The inspection found staff repeatedly delivered medication doses 75 percent higher than prescribed while failing to implement basic safety measures designed to prevent oxygen disconnections that had already caused one emergency hospitalization.
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.