Lindengrove Menomonee Falls
Lindengrove Menomonee Falls in MENOMONEE FALLS, WI — inspection on March 3, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
R297's foley catheter was discontinued.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
Nursing Student-CCC if she called APNP-FFF.
Nursing Student-CCC replied yes.
Nursing Student-CCC
Surveyor asked Nursing Student-CCC if the nurse was LPN-H.
Nursing Student-CCC replied yes and
Nursing Student-CCC informed Surveyor she was working under LPN-H and remembers bits and pieces.
Surveyor informed Nursing Student-CCC Surveyor noted she created an order for a UA.
Nursing Student-CCC informed Surveyor R297 wasn't himself, he wasn't urinating or anything.
Surveyor asked if she spoke to APNP-FFF or did she text her.
Nursing Student-CCC informed Surveyor she believes LPN-H called her.
Surveyor asked Nursing Student-CCC if she spoke to any RN about R297's change of condition.
Nursing Student-CCC informed Surveyor she's pretty sure LPN-H communicated with the DON and didn't think there was an RN in the building.
Surveyor asked Nursing Student-CCC if any of the CNAs reported anything to her about R297.
Nursing Student-CCC replied no not that I recall.
Surveyor asked Nursing Student-CCC how she was aware R297 was not urinating.
Nursing Student-CCC informed Surveyor she can't recall and doesn't know if LPN-H told her but she remembers something in that nature and thinks R297 told her he wasn't able to go. LPN-H informed Surveyor this is the first time she has sent a patient out.
On 2/17/25, at 1:50 p.m., Surveyor interviewed Director of Nursing (DON)-B and asked what the expectation is if a resident has a change of condition and the nurse on the floor is a LPN. DON-B explained they would make their observations and update the MD (medical doctor) to get further orders.
Surveyor asked if there would be a RN assessment. DON-B replied there is, they let management know and we will take a look at the resident as well.
Surveyor asked DON-B if she remembers R297. DON-B replied slightly. DON-B informed Surveyor what she remembers R297 was a pleasant man, not many complaints, he was diabetic and there wasn't a lot of issues that she was informed of. DON-B informed Surveyor she knows he scratched himself a lot and he had cream ordered for that.
Surveyor asked if there was anything ordered other than cream. DON-B replied no.
Surveyor asked DON-B if a dressing was applied, would there be an assessment. DON-B replied there should be.
Surveyor informed DON-B of APNP-FFF's note on 7/22/24 which documents two dressings. DON-B reviewed R297's record and then informed Surveyor there is no assessment.
Surveyor asked DON-B if she was involved with R297's transfer to the hospital on 8/13/24. DON-B replied no.
Surveyor asked DON-B if she was contacted regarding R297's change of condition on 8/13/24. DON-B informed Surveyor they would of contacted the on call and doesn't recall being called.
Surveyor asked who was the on call RN. DON-B informed Surveyor she doesn't know.
Surveyor asked DON-B to look up who was on call the evening of 8/13/24 and get back to Surveyor. DON-B did not provide Surveyor with the name of the on call RN.
No additional information was provided.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
interventions, and weekly wound rounds to validate appropriate support surfaces in place.
jeopardy to resident health or - Standard Skin Protocol reviewed and updated 2/17/25. safety - Skin policy and procedure reviewed.
- Updated and reviewed citation with Medical Director. - DON or designee will audit five residents weekly for comprehensive skin system compliance.
Results to QAPI (Quality Assurance and Performance Improvement).
The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following: 2.) R350 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Dementia, Pressure ulcer of right buttock, and Pressure ulcer of left heel.
R350's admission Minimum Data Set assessment was in the process of being completed.
R350's Brief Interview for Mental Status (BIMS) assessment dated [DATE], documents a score of 4, indicating that R350 is severely cognitively impaired.
R350's admission Section GG assessment dated [DATE], documents R350 requires substantial/maximum assist for bed mobility and R350 is dependent for transfers.
R350's Braden Scale Assessment used for predicting pressure ulcer risk dated 2/6/25, documents that R350 is at risk for pressure injuries. R350 has an activated Power of Attorney (POA).
R350's hospital Wound/Skin Nurse Specialist Consult note dated 2/3/25 documents, in part: [R350] has a full thickness, stage 3 pressure injury to right buttock that measures 8 x 8 x 0.1 centimeters (cm) and a stage 1 pressure injury to R350's left heel that measures 2.5 x 2.5 cm.
R350's Hospital Discharge (D/C) summary dated 2/6/25 documents, in part: . discharge diagnoses: Pressure ulcers .
You need to follow wound care instructions .
Wound Care treatment to [Right] buttock: 1.
Cleanse wound with Puracyn Plus, saturate gauze and soak 5 minutes. 2.
Pat dry with gauze. 3.
Apply 3M Cavilon barrier to peri-wound skin. 4.
Apply [NAME] Tul A over wound. 5.
Cover with Sacral Mepilex. [Registered nurse (RN)] to assess wound and change dressing three times a week. [NAME] dressings with date applied.
Wound Care treatment to heels: 1.
Cleanse wound with Puracyn Plus, saturate gauze
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
include events prior to the fall itself.
Root cause is Resident trying to self transfer with interventions to place a fall sign and offer toileting every 2-3 hours and prn.
There is not documentation of possible causative factors leading up to the fall.
There is not documentation to support the interventions implemented.
Plan of care revised. admission MDS [DATE] has bims 14/15. No fall history.
Had 1 fall after admission.
Freq incontient of B/B not toileting plan. [DATE] ED visit has laceration with stitches 1/23/2025 14:44 Nurse's Note Note Text: resident back from ER visit due to unwitnessed fall. alert and oriented making needs known. states some pain to site.
Dissolvable stitches in place to dissolve in 7 days. follow up with MD in regards. VSS resting in bed 02/13/25 08:07 AM DON this is the only information is the. I spoke to the resident.
Nurse and CNA. He was trying to get up to use the toilet.
Don't know when he was last toileted. No additional information at this time. 02/13/25 09:37 AM has white sign with black lettering on wall of TV. the sign states Sop. call don't fall. In room with wheelchair watching TV.
Has call light in reach.
Has another sign by the side if their bed.
Resident can read it and understands what it means. 1/20/25 Fall Risk Assessment completed is at risk 13 4.) R39 was admitted to the facility on [DATE] with diagnoses of Dementia, End Stage Renal Disease and Dependence on Renal Dialysis.
R39's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/25 indicates that R39 requires maximal assistance with transfers and mobility.
Surveyor reviewed R39's medical record, including physician's orders, fall risk evaluation forms and comprehensive care plans.
R39's care [TRUNCATED]
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
nurse in charge on each shift.
serve as a charge nurse on each tour of duty.
* The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule.
This deficient practice has the potential to affect all 49 residents residing in the facility.
Findings include: On 2/11/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting and 1/20/25-2/10/25.
Surveyor was provided with the nursing schedules and nurse staff postings and noted the facility's nursing schedules did not designate who the charge nurse was for each tour of duty.
On 2/17/25, at 10:15 AM, Surveyor conducted an interview with Scheduler-HHH.
Scheduler-HHH is responsible for coordinating the facility's nursing schedule and preparing the facility's nurse staff postings.
Surveyor asked Schedule-HHH if they were aware there was not a charge nurse designated on the facility's nursing schedules for Quarter 4 (July 1st -September 30th, 2024) from 1/20/25-2/10/25.
Scheduler-HHH told Surveyor that they were not aware that it is a requirement to designate a charge nurse for each shift on the daily nursing schedule.
On 2/17/25 at 2:40 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern related to the facility's schedules not designating who the facility charge nurse would be on the facility's nursing schedules for Quarter 4 (July 1st -September 30th, 2024) from 1/20/25-2/10/25 for each tour of duty.
The facility did not provide any additional information as to why it did not ensure that the facility designated a charge nurse for each tour of duty.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
that the facility will be getting all new kitchen staff. No other information has been provided at this
On 2/17/25, at 8:59 AM, Surveyor observed Resident room breakfast trays being distributed.
Surveyor
carried a tray from the cart down to room [ROOM NUMBER] with uncovered oatmeal and applesauce, placed the tray on the isolation cart, donned a gown and went into the room.
On 2/17/25, at 9:06 AM, Surveyor observed CNA-FF carry a room tray from the cart still parked at 102 to room [ROOM NUMBER] and the applesauce is not covered.
On 2/17/25, at 9:12 AM, Surveyor observed CNA-EE carry a tray from the cart still parked at 102 with uncovered applesauce to room [ROOM NUMBER].
This is approximately 3 rooms down and across the hallway.
On 2/17/25, at 9:13 AM, Surveyor observed CNA-EE carry a tray from the cart still parked at 102 with uncovered cereal and applesauce, put the tray on isolation cart, and donned gown and gloves outside of room [ROOM NUMBER] and took the tray to room [ROOM NUMBER].
No additional information was provided.
F-F686.
Education provided on 2/18/2025. safety - Facility skin sweep done by midnight 2/17/25.
- All skin care plans updated and individualized per skin sweep observations completed by 2/20/25 which included support surface assessments and updates.
- Weekly comprehensive wound rounds to continue with RN and NP.
- Skin care plans will be reviewed weekly with clinical IDT focus meeting to ensure support surface interventions, and weekly wound rounds to validate appropriate support surfaces in place.
- Standard Skin Protocol reviewed and updated 2/17/25.
- Skin policy and procedure reviewed.
- Updated and reviewed citation with Medical Director.
- DON or designee will audit five residents weekly for comprehensive skin system compliance.
Results to QAPI (Quality Assurance and Performance Improvement).
The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following:
49435
2.) R350 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Dementia, Pressure ulcer of right buttock, and Pressure ulcer of left heel.
R350's admission Minimum Data Set assessment was in the process of being completed.
R350's Brief Interview for Mental Status (BIMS) assessment dated [DATE], documents a score of 4, indicating that R350 is severely cognitively impaired.
R350's Admission Section GG assessment dated [DATE], documents R350 requires substantial/maximum assist for bed mobility and R350 is dependent for transfers.
R350's Braden Scale Assessment used for predicting pressure ulcer risk dated 2/6/25, documents that R350 is at risk for pressure injuries. R350 has an activated Power of Attorney (POA).
R350's hospital Wound/Skin Nurse Specialist Consult note dated 2/3/25 documents, in part: [R350] has a full thickness, stage 3 pressure injury to right buttock that measures 8 x 8 x 0.1 centimeters (cm) and a stage 1 pressure injury to R350's left heel that measures 2.5 x 2.5 cm.
525421
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525421 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.