Lindengrove New Berlin: Fall Investigation Failures - WI
The fall was unwitnessed. Nobody on the care staff had seen it happen.
Inspectors reviewing the incident found that Lindengrove New Berlin's investigation stopped well short of answering the questions that would have mattered. The facility never determined who had last observed the resident before she went down. It never documented what she had been doing, how she had been positioned, or when she had last been taken to the bathroom. It did not examine whether the fall-prevention interventions already on her care plan had been in place at the time, or whether any of them were still working.
The facility updated her care plan to move her meals near the nurses' station.
The July fall was not the first one inspectors examined. A separate fall on June 26 drew the same finding: the investigation was incomplete. In that case, the interdisciplinary team concluded the resident had simply failed to call for help before getting up. A soft-touch call light was added to the care plan. Inspectors again noted that no one had documented who last saw her, what she had been doing, how she was lying in bed, or whether the interventions already in place had actually been there when she fell.
The resident carried a long list of diagnoses: hemiplegia and hemiparesis following a stroke affecting her right dominant side, generalized muscle weakness, polyarthritis, type 2 diabetes, vitamin D deficiency, unsteadiness on feet, and repeated falls as a documented condition in its own right.
The nurses' note documenting the July 7 dining room fall was created on August 21, six weeks after the incident.
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.
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 New Berlin in NEW BERLIN, WI was cited for violations during a health inspection on September 8, 2025.
Nobody on the care staff had seen it happen.
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.