Lindengrove Menomonee Falls

F-F686. Education provided on 2/18/2025. safety - Facility skin sweep done by midnight 2/17/25. Residents Affected - Few - 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.) Resident R350 was admitted to the facility on [DATE REDACTED] with diagnoses that include Alzheimer's disease, Dementia, Pressure ulcer of right buttock, and Pressure ulcer of left heel.

Resident R350's admission Minimum Data Set assessment was in the process of being completed.

Resident R350's Brief Interview for Mental Status (BIMS) assessment dated [DATE REDACTED], documents a score of 4, indicating that Resident R350 is severely cognitively impaired.

Resident R350's Admission Section GG assessment dated [DATE REDACTED], documents Resident R350 requires substantial/maximum assist for bed mobility and Resident R350 is dependent for transfers.

Resident R350's Braden Scale Assessment used for predicting pressure ulcer risk dated 2/6/25, documents that Resident R350 is at risk for pressure injuries. Resident R350 has an activated Power of Attorney (POA).

Resident R350's hospital Wound/Skin Nurse Specialist Consult note dated 2/3/25 documents, in part: [Resident 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 Resident R350's left heel that measures 2.5 x 2.5 cm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Resident 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 Level of Harm - Immediate wound with Puracyn Plus, saturate gauze and soak 5 minutes. 2. Pat dry with gauze. 3. Apply 3M Cavilon jeopardy to resident health or barrier to peri-wound skin. 4. Apply [NAME] Tul A over wound. 5. Cover with Sacral Mepilex. [Registered safety 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 Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20483 Residents Affected - Few Based on observation, record review and interview, the facility did not ensure that residents received adequate supervision and assistance to prevent accidents. The facility did not thoroughly assess falls and accidents for causative factors. The facility did not ensure fall interventions were implemented. This was observed with 6 (Resident R12, Resident R23, Resident R36, Resident R39, Resident R346 and Resident R347) of 6 residents reviewed for accidents.

* Resident R12's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions

* Resident R23's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions

* Resident R36 was observed not to have their call light not in reach per his falls plan of care.

* Resident R39's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions

* Resident R346 and Resident R347's falls were not thoroughly assessed for causative factors.

Findings include:

The facility's policy and procedure Falls dated 12/5/24. The policy documents that preventative measures are put in place to reduce the occurrence of falls and risk of injury from falls.

The procedures include:

- Licensed nurse completes electronic documentation of the Fall Incident Report.

- The care plan will be updated with an identified intervention.

- Registered Nurse reviews and completes the fall assessment and interventions.

- Fall follow-up assessments completed as indicated.

- The (Interdisciplinary Team) IDT will review Fall Incident report and utilize root cause analysis to make further recommendations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 2/11/25, at 3:55 p.m., Surveyor interviewed Director of Nursing (DON)-B regarding the facility's fall process. DON-B informed Surveyor when ever there is a fall the staff check out the resident, ask the resident Level of Harm - Actual harm what happened, what they were trying to do and get statements from the aides as to when the resident was last toileted, what were they doing, were they in bed, and what was going on before the fall. Staff calls the Residents Affected - Few POA (power of attorney), NP (Nurse Practitioner), herself, and the case worker. The resident is placed on the 24 hour board and neuro checks should be charted on. Residents are monitored for three days and if there is any injury they let the NP know and get orders to send them out. Surveyor inquired if anyone reviews the falls. DON-B informed Surveyor the IDT (interdisciplinary team) reviews fall in the morning meeting explaining they read the notes, try to determine what happened. If there is not a clear picture they will ask the resident and follow up with the nurses. DON-B informed Surveyor the nurses are suppose to put in an immediate intervention and they follow up. Surveyor asked if anyone reviews to see if prior interventions were in place. DON-B explained they have a weekly meeting where they go over everything including risk, wounds, injuries. Surveyor asked if anyone follows up with the CNAs. DON-B informed Surveyor they try to follow up and the CNAs shouldn't write they don't know but sometimes its difficult to get a hold of them.

1.) Resident R12's diagnoses includes vascular dementia and is receiving hospice care.

Resident R12's significant change MDS (minimum data set) with an assessment reference date of 11/27/24 has a BIMS (brief interview mental status) score of 1 which indicates severe cognitive impairment. Resident R12 is assessed as being dependent for toileting hygiene, roll left & right, chair/bed to chair transfer and toilet transfer. Resident R12 is assessed as being always incontinent of urine and bowel. Resident R12 is assessed as not having any falls since prior assessment.

Resident R12's Falls CAA (care area assessment) dated 11/29/24 under analysis of findings for nature of problem documents At risk for fall progressive weakness-recent admit to hospice services-assisted to safely transition surfaces. Daily meds (medication) add to risk potential. Under care plan considerations documents Continue with care plan. Continue to assist to safely transition and reposition. Goal to maintain safety without fall. Falls place at risk for injury.

Resident R12's fall risk evaluation dated 8/19/24 has a score of 15. Under instructions documents Assess the resident status below. If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.

Resident R12's fall risk evaluation dated 9/12/24 has a score of 15 which indicates high risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident R12's at risk for falls care plan initiated & revised on 7/12/24 documents the following interventions: PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed). Initiated 11/5/23. Level of Harm - Actual harm Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.

The resident needs prompt response to all requests for assistance. Initiated 7/12/24 & revised 8/19/24. Residents Affected - Few Ensure that the resident is wearing appropriate footwear (Shoes/socks with nonskid soles) when ambulating, transferring or mobilizing in w/c (wheelchair). Initiated 7/12/24 & revised 8/19/24. The resident needs a safe environment with a working and reachable call light, personal items within reach. Initiated 7/24/24 & revised 8/19/24. Bed in lowest position with floor mat when in bed. Initiated 8/19/24. Staff to assist resident to bed

after breakfast if allows. Initiated 8/19/24. Staff to check and change q (every) 2 to 3 hours and prn if allows. Initiated 8/19/24. Body pillow when in bed. Initiated 9/12/24. Transfer bar to assist with bed mobility. Initiated 9/26/24 & revised 12/9/24. Air mattress with bolsters. Initiated 12/11/24 & revised 12/13/24. Air mattress - check function q (every) shift and prn (as needed). Initiated 12/11/24.

Resident R12's nurses note dated 9/12/24 at 21:27 (9:27 p.m.) written by Licensed Practical Nurse (LPN)-J documents Nurse went to give resident medication at about 6.30 PM and found resident on the floor by bed. Resident fell on the floor mat and was laying on her left side. Evaluation of all limbs functioning and moving well. Resident had a neuro check and vitals done and will be ongoing. Resident had a bm (bowel movement) and was cleaned up by CNA's and was placed in Hoyer to be put back into bed. No injury noted at the time of the assessment.

Surveyor reviewed the facility's fall investigation provided by Director of Nursing (DON)-B for Resident R12's fall on 9/12/24. Surveyor noted the facility investigation does not include whether prior interventions were in place at

the time of Resident R12's fall.

Resident R12's fall risk evaluation dated 9/26/24 has a score of 13 which indicates high risk.

Resident R12's nurses note dated 9/26/24 at 11:36 a.m. written by LPN-HH documents Resident had an unwitnessed fall and was found by med tech at 0635 (6:35 a.m.). Resident was face down on ground. Tech alerted nurse and nurse went to residents room. Nurse assessed resident. Resident c/o (complained of) head and left shoulder pain. Neuro checks started, vitals taken. DON (Director of Nursing), ADON (Assistant Director of Nursing), and NP (Nurse Practitioner), POA (Power of Attorney) notified. NP assessed resident as well. Resident alert as morning progresses and denies any pain in head or shoulder. Pupils reactive, normal ROM (range of motion) as resident had before fall. ADON talked to residents POA about transfer bars. No signs of injuries or bleeding.

Surveyor reviewed facility's fall investigation provided by DON-B for Resident R12's fall on 9/26/24. Surveyor noted the facility did not conduct a thorough investigation of Resident R12's fall as there are no staff statements or evidence staff was spoken to as to when was Resident R12 last seen, toileted, what was Resident R12 doing, etc. There is no information as to whether prior interventions such as the body pillow were in place at the time of Resident R12's fall.

Resident R12's fall risk evaluation dated 12/11/24 has a score of 13 which indicates high risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident R12's nurses note dated 12/11/24 at 10:45 a.m. written by LPN-WW documents Writer was called into the room around 6:45 this morning to find resident lying on the floor by her bed on her right side. Resident was Level of Harm - Actual harm alert/orient and responsive. Resident was assessed and assisted with Hoyer lift back into bed. Resident has small bump to right side of head. Resident denies any pain or discomfort @ (at) this time. VSS (vital signs Residents Affected - Few stable). ROM (range of motion) per usual. Hospice was called and Nurse [Name] came out to assess pt. as well. NOR (new order received) to D/C (discontinue) neuro check and one time order for dilaudid. Husband was called and updated as well as DON and administrator. Will continue to monitor this shift.

Surveyor reviewed facility's fall investigation provided by DON-B for Resident R12's fall on 12/11/24. Surveyor noted

the facility did not conduct a thorough investigation of Resident R12's fall as the two day shift staff statements indicates they didn't know when Resident R12 was last toileted or repositioned as this fall occurred shortly after the day shift started. There are no statements or indications the night shift staff was interviewed as to who last saw Resident R12, when was Resident R12 toileted or repositioned. CNA (Certified Nursing Assistant)/Med Tech-KK's statement includes documentation of matt not in place on floor, bed not in lowest position. There is no indication as to whether the prior intervention of the body pillow was in place at the time of Resident R12's fall.

On 2/11/25, at 7:17 a.m., Surveyor observed Resident R12 in bed on the right side with the bed in the lowest position and a mat on the floor along the left side of Resident R12's bed. Surveyor observed there isn't a body pillow on the left side. The right side of Resident R12's bed is against the wall.

On 2/11/25, at 7:36 a.m. Surveyor observed Certified Nursing Assistant (CNA)-K in Resident R12's room and is wearing gloves. CNA-K placed the wash basin on the over bed table, removed the floor mat, and informed Resident R12 she was going to get her up, dressed, and go down for breakfast. CNA-K raised the height of bed and positioned Resident R12 on her back. CNA-K unfastened the incontinence product which Surveyor observed contained urine. CNA-K informed Resident R12 she was going to wash her peri area and washed Resident R12's inner thighs and frontal perineal area. CNA-K positioned Resident R12 on the right side, and removed the soiled incontinence product and informed Resident R12 she was going to put the brief under her. As CNA-K was attempting to place the incontinence product under Resident R12, Resident R12's knee kept hitting the wall on the right side. CNA-K removed her gloves and left Resident R12's room. Prior to leaving Resident R12's room, CNA-K did not lower Resident R12's bed and did not place

the body pillow or mat on the floor. CNA-K reentered Resident R12's room with a sheet, placed gloves on, folded the sheet and placed the sheet under Resident R12 & straightened out the incontinence product by positioning Resident R12 from side to side. CNA-K pulled up the incontinence product between Resident R12's thighs and fastened the product. CNA-K placed pants on Resident R12, removed Resident R12's shirt and placed a Hoyer sling under Resident R12. CNA-K washed Resident R12's upper body, placed a sweater on Resident R12, and stated to Resident R12 she was going to lower her down while she goes to get help. CNA-K lowered the bed down, removed her gloves and left Resident R12's room at 7:51 a.m. CNA-K did not place the body pillow on Resident R12's bed or the mat on the floor prior to leaving Resident R12's room. At 7:53 a.m. CNA-K and CNA-LL entered Resident R12's room, placed gloves on, and transferred Resident R12 from the bed into the broda chair using a Hoyer lift.

On 2/11/25, at 7:25 a.m., Surveyor asked CNA-K if they use the body pillow. CNA-K replied yes at night. Surveyor informed CNA-K Surveyor did not observe the body pillow on Resident R12's bed this morning.

On 2/11/25, at 8:37 a.m., Surveyor observed Resident R12 sitting in a broda chair along side a table in the dining room. Surveyor observed there is a pillow between Resident R12's knees and a pink U shaped pillow around Resident R12's neck.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 2/11/25, at 8:55 a.m., Surveyor observed Resident R12 continues to be along side the table in the dining room. Resident R12 has a spoon in her hand and is eating oatmeal. Level of Harm - Actual harm

On 2/11/25, at 9:31 a.m., Surveyor observed CNA-K wheel Resident R12 into her room and left Resident R12's room Residents Affected - Few immediately.

On 2/11/25, at 9:51 a.m. Surveyor observed Resident R12 sitting in a broda chair, which is slightly reclined back in her room holding onto a pillow with the pink u shaped pillow on Resident R12's lap.

On 2/11/25, at 10:27 a.m., Surveyor observed Resident R12 continues to be sitting in the broda chair in her room and has thrown the two pillows on the floor.

On 2/11/25, at 10:43 a.m., Surveyor asked CNA-K if Resident R12 lays down during the day. CNA-K informed Surveyor after lunch she goes back to bed. Surveyor asked CNA-K if Resident R12 lays down after breakfast. CNA-K replied just lunch. Surveyor noted there is a fall intervention to lay down Resident R12 after breakfast.

On 2/11/25, at 11:09 a.m. Surveyor asked Registered Nurse/Wound Nurse (RN/WN)-I if a resident has fall interventions like a body pillow should they be in place. RN/WN-I replied they should have a body pillow. Surveyor asked if the intervention is a fall mat should the mat be next to the bed. RN/WN-I replied yes because you don't know what will happen, a fall can happen that quick. Surveyor informed RN/WN-I of the

observations of Resident R12's fall interventions not in place.

On 2/11/25, at 11:24 a.m., Surveyor observed Resident R12's call light was activated. Surveyor entered Resident R12's room and observed Resident R12 sitting in the broda chair holding onto the call light. Surveyor asked Resident R12 if she put her call light on. Resident R12 put the call light up to her hear stating hello, hello.

On 2/11.25, at 2:44 p.m., Surveyor observed Resident R12 awake in bed on her left side. Surveyor observed Resident R12's bed is in the low position with the body pillow along the left side but the mat is not the floor next to Resident R12's bed. Surveyor observed the floor mat is propped up against the recliner in the corner.

On 2/11/25, at 3:36 p.m., Surveyor observed Resident R12 continues to be in bed awake on her left side. Surveyor observed the body pillow continues to be propped up against the recliner and is not on Resident R12's bed according to Resident R12's plan of care.

On 2/13/25, at 2:18 p.m., Surveyor informed DON-B of Surveyor's concerns of fall interventions observed not

in place for Resident R12 and facility's investigation for Resident R12's falls on 9/12/24, 9/26/24, & 12/11/24 were not thoroughly investigated to prevent further falls.

2.) Resident R23's diagnoses includes congestive heart failure, depression, diabetes mellitus, glaucoma, macular degeneration, and atrial fibrillation. Resident R23 receives hospice care.

Resident R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 has a BIMS (brief

interview mental status) score of 1 which indicates severe cognitive impairment. Resident R23 is assessed as requiring partial/moderate assistance for toileting hygiene, roll left & right and toilet transfers. Resident R23 is assessed as requiring substantial/maximal assistance for chair/bed to chair transfer. Resident R23 has an indwelling catheter and is frequently incontinent of bowel. Resident R23 is assessed as not having any falls prior to admission or since admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident R23's fall CAA (care area assessment) dated 11/11/24 under analysis of findings for nature of the problem/condition documents Hx (history) syncope due to orthostatic hypotension adm (admission) fall Level of Harm - Actual harm score=10 indicates risk. Decreased vision/vision Dx (diagnosis). At fall risk-assisted to safely transition surfaces. Under care plan considerations documents Proceed to care plan. Maintain safety throughout her Residents Affected - Few stay. Falling places at risk for injury/Fx (fracture).

Resident R23's fall risk evaluation dated 11/1/24 has a score of 10. Under instructions documents Assess the resident status below. If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.

Resident R23's high risk for falls care plan initiated & revised on 11/1/24 documents the following interventions:

Anticipate and meet the resident's needs. Initiated 11/1/24. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 11/1/24 & revised 12/9/24. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Initiated 11/1/24. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Initiated 11/1/24 & revised 11/5/24. Ensure that the resident is wearing appropriate footwear non skid socks when ambulating, transferring or mobilizing in w/c (wheelchair). Initiated & revised 11/1/24. Follow facility fall protocol. Initiated 11/1/24. PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed). Initiated 11/1/24. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Initiated 11/1/24. The resident needs a safe environment with: SPECIFY even floors from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, personal items within reach. Initiated 11/1/24. Staff to ensure pillows are arranged on cough sic (couch) as resident allows. Initiated 11/17/24. Call don't fall sign. Initiated 12/10/24. Bedside commode. Initiated 12/13/24. Mattress with bolsters. Initiated 12/13/24. Body pillow when in bed if allows. Initiated 12/14/24. Recliner chair with lever replaced with recliner chair with remote for easier use. Initiated 1/22/25. Recliner chair replaced with chair that does not recline. Initiated 1/23/25. Resident to sit in Broda chair when out of bed when resident allows. Initiated 1/23/25 & revised on 1/24/25.

Resident R23's ADL (activities daily living) self-care performance deficit care plan initiated 11/1/24 includes an intervention of Transfer with assist of 1 with gait belt and walker. Initiated & revised 11/1/24.

Resident R23's nurses note dated 11/17/24, at 13:41 (1:41 p.m.), written by Licensed Practical Nurse (LPN)-H documents Resident had an UWF (unwitnessed fall) this morning. Upon checking resident was continent of B/B (bowel/bladder) with proper footwear on. Resident denies having any pain. No injuries were found after head/toe observation. Resident was fixing something on her couch when she lost her balance and fell on the floor. She crawled to her recliner chair to push her call light for help. She was then helped off the floor and helped into her recliner chair and was reeducated on calling for help before getting up. Resident son was informed of the fall when he came in to visit this morning, hospice notified and NP (Nurse Practitioner).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Surveyor reviewed Resident R23's fall investigation emailed by Director of Nursing (DON)-B on 2/12/25. Surveyor noted there are no statements or interviews with staff as to who last saw Resident R23, what was Resident R23 doing etc. Level of Harm - Actual harm There is no information as to whether previous interventions were in place.

Residents Affected - Few On 2/13/25, at 2:20 p.m., Surveyor interviewed DON-B regarding Resident R23's fall on 11/17/24 and inquired if there are any staff statements/interviews. DON-B informed Surveyor she doesn't think she has any.

Resident R23's nurses note dated 12/13/24, at 10:17 a.m., written by LPN-HH documents Resident had a witnessed fall while getting up to go take a shower with CNA (Certified Nursing Assistant). Resident got dizzy, fell backward and hit her head on a wood side table. Residents head was bleeding and nurse stopped the bleeding with applied pressure. Resident said her head did not hurt when asked. Nurse called emergency contact and left a message for him to call back. [Name] hospice was notified. Neuro checks started.

Surveyor reviewed the facility's fall investigation emailed by DON-B on 2/12/25. The root cause documents resident was being assisted to bathroom by CNA with wheeled walker, got dizzy and lost balance causing her to be lowered to the floor.

On 2/13/25, at 2:21 p.m., Surveyor interviewed DON-B regarding Resident R23's fall on 12/13/24. Surveyor asked if Resident R23 was lowered to the floor how did she sustain a hematoma to the back of Resident R23's head and was the CNA using a gait belt according to Resident R23's plan of care. DON-B informed Surveyor she can't say if the gait belt was being used and lowered to the floor was probably a typo. Surveyor asked DON-B to get back to Surveyor with any further information regarding Resident R23's 12/13/24 fall. DON-B did not provide Surveyor with any further information.

Resident R23's nurses note dated 12/14/24, at 05:49 (5:49 a.m.), written by Nurse Extern-XX documents Resident had a unwitnessed fall. Resident was trying to get out of bed. Gash noted from previous fall, no bleeding observed. Hospice nurse, POA, NP notified. resident did say she has no pain. Surveyor noted this fall occurred on 12/13/24 at 6:37 p.m.

Surveyor reviewed the facility's fall investigation emailed by DON-B on 2/12/25. Surveyor noted there are no statements or interviews with staff as to who last saw Resident R23, what was Resident R23 doing etc. There is no information as to whether previous interventions were in place.

On 2/13/25, at 2:24 p.m., Surveyor interviewed DON-B regarding Resident R23's fall on 12/13/24 which was documented on 12/14/24. DON-B informed Surveyor there are not any staff statements.

Resident R23's nurses note dated 12/14/24, at 20:27 (8:27 p.m.) written by Nurse Extern-P documents UWF (unwitnessed fall) Resident was lying on the floor in front of bed on her back, assessed resident, resident said she has no pain, took vitals, resident said she is feeling ok. contacted NP, tried to contact son [Name] no answer tried contacting ADON (Assistant Director of Nursing) no answer.

Surveyor reviewed the facility's investigation emailed by DON-B on 2/12/25. Surveyor noted the facility did not have a thorough investigation there are no staff statements/interviews as to who last saw Resident R23, was Resident R23 incontinent, what was Resident R23 doing prior and whether prior interventions were in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 2/13/25, at 2:25 p.m., Surveyor interviewed DON-B regarding Resident R23's fall on 12/14/24. Surveyor informed DON-B there are no staff statements/interviews as to who last saw Resident R23, what was she doing and were prior Level of Harm - Actual harm interventions in place. Surveyor asked DON-B if the body pillow is a current intervention. DON-B informed Surveyor it's on her care plan so it's a fall intervention. Surveyor informed DON-B Surveyor has not observed Residents Affected - Few Resident R23's body pillow.

Resident R23's nurses note dated 1/21/25, at 21:20 (9:20 p.m.) written by LPN-H documents Resident was found on her floor in front of her wheelchair face down upon observation she has and large knot above her right eye, Ice was applied to the right eye. Resident had on proper footwear and was continent upon fall. Resident was asked if she would like to go to hospital and she refused, resident isn't on any blood thinners. Family, Hospice, NP and DON were informed. Neuro checks started. Family came up to facility to check on resident will let me know if they would like for her to be sent out to hospital.

Surveyor reviewed the facility's investigation emailed by DON-B on 2/12/25. Surveyor noted CNA-YY's statement for time of incident 8:50 p.m. for the question when was the last time you saw the resident and what were they doing documents I saw her at 8:00 PM. She was sitting in recliner watching TV. For the question was the call light on a the time of the fall and was it within reach documents No I was in room at time. Surveyor noted this information is conflicting.

On 2/13/25, at 2:26 p.m., Surveyor interviewed DON-B regarding the facility's fall investigation regarding Resident R23's fall on 1/21/25 at 8:50 p.m. Surveyor informed DON-B CNA-YY's statement documents she last saw Resident R23 at 8:00 p.m. but documents the call light was not on because she was in the room at the time. DON-B informed Surveyor she doesn't think she understood the questions. Surveyor asked DON-B if she asked CNA-YY if she was in Resident R23's room when 23 fell . DON-B replied I didn't ask her.

Resident R23's Certified Nursing Assistant (CNA) kardex as of 2/11/25 under the transfer section documents Transfer with assist of 1 with gait belt and walker.

On 2/10/25, at 1:49 p.m., Surveyor observed Resident R23 sitting in a wheelchair in her room. There is a burgundy colored mat on the floor on the right side of Resident R23's bed.

On 2/10/25, at 3:41 p.m., Surveyor observed Resident R23 sitting in a wheelchair facing the bed. Surveyor observed Resident R23's call light is resting on the floor next to Resident R23's bed by the floor mat.

On 2/11/25, at 7:14 a.m., Surveyor observed Resident R23 in bed on her back. Resident R23's bed is in the low position, there is a mat on the floor on the right side and the call light is attached to the sheet on the right side hanging down. Surveyor did not observe the body pillow on Resident R23's bed.

On 2/11/25, at 8:09 a.m., Surveyor observed Resident R23 continues to be in bed on her back. Surveyor observed there is still not a body pillow on Resident R23's bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 2/11/25, at 10:36 a.m., CNA-K entered Resident R23's room and placed gloves on. CNA-K informed Surveyor she will put on her socks after she is finished brushing her teeth. Surveyor observed Resident R23 is sitting on the edge of Level of Harm - Actual harm the bed brushing her teeth. At 10:37 a.m. CNA-K placed tubi grips on Resident R23's bilateral lower extremities and then placed gripper socks on. CNA-K asked Resident R23 if she wants to lay down or sit up. Resident R23 informed CNA-K she Residents Affected - Few wants to sit in the wheelchair. CNA-K moved Resident R23's wheelchair closer to the bed, placed the urinary collection bag under Resident R23's wheelchair, held under Resident R23's left arm & back and assisted Resident R23 with standing, Resident R23 took a couple steps to turn and sit in the wheelchair. CNA-K did not use a gait belt according to Resident R23's plan of care.

On 2/11/25, at 11:39 a.m., Surveyor asked CNA-K if she ever uses a gait belt when transferring Resident R23. CNA-K replied no, just walker, used to be in care plan but hospice took it out.

On 2/11/25, at 2:42 p.m., Surveyor observed Resident R23 sleeping in bed on her back. Surveyor observed the bed is not at the lowest position, there is no floor mat on the right side and the body pillow is not on Resident R23's bed.

On 2/11/25, at 3:38 p.m., Surveyor observed Resident R23 continues to be sleeping in bed on her back. Surveyor observed the bed is not at the lowest position, there is not a body pillow on Resident R23's bed and there is not a floor mat on the right side of the bed.

On 2/13/25, at 7:27 a.m., Surveyor observed Resident R23 in bed on her back. Surveyor observed the bed is at the lowest position, there is a blue mat floor mat on the right side but there is no body pillow observed.

On 2/13/25, at 7:36 a.m., Surveyor asked CNA/Med Tech-KK when Resident R23 is in bed should there be a floor mat

on the right side of Resident R23's bed. CNA/Med Tech-KK replied yes.

On 2/13/25, at 2:18 p.m., Surveyor asked DON-B if Resident R23 should be transferred with a gait belt. DON-B replied if that is what the care plan says, yes. Surveyor informed DON-B of the observation of Resident R23 being transferred without a gait belt and Surveyor had observed gait belt hanging on the back of Resident R23's door. Surveyor also informed DON-B of other fall interventions, mat on floor and body pillow not being in place.

No additional information was provided.

21855

Based on [NAME], [NAME], [NAME], [NAME] and [NAME]

7 of 7 reviewed for falls.

[NAME] schroederus sustained a fall leading to hospitalization where resident required stiches

[NAME] did not have through investigation related to picture frame falling off the wall and call light not within reach

[NAME] and [NAME] fall investigation not through and interventions not in place

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 [NAME] and Odelle not throughly investigated falls

Level of Harm - Actual harm Resident #15

Residents Affected - Few Accidents

02/10/25 10:21 AM bruise on right eye. Was reaching from bed and fell .

Call light

1/23/2025 07:23 Nurse's Note

Note Text: writer called to resident room due to unwitnessed fall. resident found in lying position to right side. upon assessment writer noticed bleeding to to right eye. Resident states he was in sitting position on bed when he attempted to help himself and fell . call light was in reach but not on. resident alert making needs known answering questions appropriately. Call out to NP and family ok to send resident to ER to eval and treat.

Plan Of Care:

The resident is High risk for falls r/t

Deconditioning, Gait/balance problems,

Incontinence

Date Initiated: 01/20/2025

Revision on: 01/20/2025

Risk of falls/falls with injury will

be minimized

Date Initiated: 01/20/2025

Target Date: 04/20/2025

CANCELLED: Anticipate and meet The resident's needs.

Date Initiated: 01/20/2025

Revision on: 01/21/2025

Cancelled Date: 01/21/2025

CNA

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 LPN

Level of Harm - Actual harm RN

Residents Affected - Few 01/21/2025

Be sure the resident's call light is within reach and encourage the resident to use it

for assistance as needed. The resident needs prompt response to all requests for

assistance.

Date Initiated: 01/20/2025

Revision on: 01/20/2025

CNA

LPN

RN

Educate the resident/family/caregivers about safety reminders and what to do if a

fall occurs.

Date Initiated: 01/20/2025

LPN

RN

Encourage the resident to participate in activities that promote exercise, physical

activity for strengthening and improved mobility

Date Initiated: 01/20/2025

Revision on: 01/20/2025

LPN

CNA

RN

Ensure that The resident is wearing appropriate footwear non-skid socks when

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 ambulating, transferring or mobilizing in w/c.

Level of Harm - Actual harm Date Initiated: 01/20/2025

Residents Affected - Few Revision on: 01/20/2025

CNA

LPN

RN

fall-1/23/25-bed in lowest position with mat on floor when in bed

Date Initiated: 01/23/2025

CNA

LPN

RN

fall-1/23/25-call don't fall sign in room

Date Initiated: 01/23/2025

CNA

LPN

RN

fall-1/23/25-staff to offer toileting q 2 to 3 hours and prn

Date Initiated: 01/23/2025

CNA

LPN

RN

PT/OT evaluate and treat as ordered or PRN.

Date Initiated: 01/20/2025

02/11/25 08:13 AM In room . Dressed in wheelchair watching TV. Has splint and 1/2 table.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 02/11/25 09:29 AM reviewed fall investigation by DON La. Just has follow-up interventions. Does not include events prior to the fall itself. Root cause is Resident trying to self transfer with interventions to place a fall Level of Harm - Actual harm 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. Residents Affected - Few Plan of care revised.

Admission MDS 1/27/25 has bims 14/15. No fall history. Had 1 fall after admission. Freq incontient of B/B not toileting plan.

1/23/25 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

42037

4.) Resident R39 was admitted to the facility on [DATE REDACTED] with diagnoses of Dementia, End Stage Renal Disease and Dependence on Renal Dialysis.

Resident R39's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/25 indicates that Resident R39 requires maximal assistance with transfers and mobility.

Surveyor reviewed Resident R39's medical record, including physician's orders, fall risk evaluation forms and comprehensive care plans.

Resident R3 [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 42037

Residents Affected - Many Based on observation, interview, and record review, the facility did not designate a licensed nurse to 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21855

Residents Affected - Many Based on observation, interview and record review, the facility did not ensure food was prepared, and served, in a sanitary manner. This was observed in 2 of 2 food preparation and serving areas and with the meal tray service to resident rooms on 1 (Unit A) of 4 units.

* The facility did not ensure the facility kitchen dish machine was functioning to sanitize dishware.

* The dietary staff was observed without hair restraints in the 1st floor kitchen preparation and serving area and the main kitchen.

* On Unit A resident meal trays items were not covered during delivery to resident rooms.

* The facility kitchen dish machine was not monitored, and checked, to ensure appropriate sanitization of dishware.

Findings include:

On 2/11/25, at 12:16 PM, the Food Service Director (FSD)-W provided policy and procedures to Surveyor. There is no date of review, or revision, on the policy and procedures. The FSD-W does not know the dates and this what they use.

The facility's policy and procedure with no date and titled, Hair Restraints documents that all staff entering a kitchen will wear a hairnet/hair restraint, ensuring that all hair is completely covered by the hairnet.

The facility's policy and procedure with no date and tilted, Recording Dish Machine Temperatures documents that all staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal.

The facility's policy and procedure with no date and titled, Manual Dishwashing documents that all flatware, serving dishes, cookware will be washed, rinsed and sanitized after each use. The policy states that the dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation.

1.) On 2/10/25, at 11:38 AM, Surveyor observed the 1st floor kitchen area. The 1st floor kitchen service area has hairnet boxes by both entrances. There is signs in the doorways to use a hair restraint when entering.

The lunch service was being prepped by Dietary Aide (DA) -X and DA-V. DA-V was observed with a medium length beard that was uncovered. DA-V was setting up meal trays and place settings in the dining room. The meal trays were being set-up on the steam table food handling area.

On 2/10/25, at 12:10 PM, DA-V brought the hot food cart into the kitchen area. DA-V now is wearing a beard covering.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 2/10/25, at 12:14 PM, DA-X removed the hot food items from the hot cart and into the food steamer. DA-X was observed with a hairnet on the top portion of their hair bun. DA-X hair on their head itself was Level of Harm - Minimal harm or uncovered. DA-X placed the hot food items into the serving steam table. DA-X obtained food temperatures of potential for actual harm the food items in the steam table. After this was completed, Surveyor queried DA-X regarding hair restraints. DA-X stated they do not have any large enough to cover their entire head. DA-X stated they only cover their Residents Affected - Many top bun. At this time (FSD) -W entered the kitchen area. DA-X requested a larger hairnet from FSD-W. The FSD-W did provide DA-X with a larger hair restraint.

On 2/11/25, at 9:10 AM, Surveyor observed Cook-Y in the main kitchen by the food preparation area. Cook-Y has a medium length beard. Cook-Y was wearing a beard hair restraint underneath their beard. DA-V was observed by the dish machine area. DA-V has a medium length beard. DA-V did not have a hair restraint over their beard.

On 2/11/25, at 2:05 PM, Surveyor interviewed the Regional Food Service Director (RFSD)-Z and the FSD-W. Both stated staff should be utilizing hair restraints in the kitchen areas.

On 2/11/25, at 3:09 PM, at the facility exit meeting, Surveyor shared the hair restraint concerns with Nursing Home Administrator (NHA) -A, Regional Nurse Consultant (RNC)-N and Director of Nurses (DON) -B.

2.) 02/11/25, at 9:54 AM, Surveyor observed Dietary Aide (DA)-V emptying a used meal tray cart. DA-V went over by the dish machine loading area. DA-V stated they typically use a sticker for testing the dish machine. DA-V stated they don't look, or log, the dish machine temperatures. DA-V stated they did not test the dish machine temperature yet. DA-V has not seen the dish machine log sheet. DA-X came and took over emptying the used food carts. DA-X stated they did not know where the temperature logs were. DA-V was observed utilizing the dish machine with dishware.

Surveyor requested the dish machine logs from Food Service Director (FSD) -W. The FSD-W also looked around the kitchen for the dish machine logs and could not locate them. The FSD-W stated they will look for them.

On 2/11/25, at 11:18 AM, the FSD-W provided Surveyor a clipboard with the dish machine logs.

Surveyor noted the dish machine logs do not include temperature documentation for each meal use of the dish machine. The dish machine logs have AM and PM headers with one entry of a temperature test strip for 2/11/25 AM.

Surveyor noted there was no dish machine log temperature documentation for September 2024, November 2024, December 2024, January 2025 and February 1 - 10. Surveyor noted the August 2024 dish machine log has no temperature documentation for the following dates in August 2024: 3, 8, 11,12,13,14,15,17 and 31.

Surveyor noted that the dish machine logs did have documentation of proper sanitization with use. There is not a additional system to ensure dish ware is being sanitized correctly.

On 2/11/25, at 2:05 PM, Surveyor interviewed Regional Food Service Director (RFSD)-Z and FSD-W. Both stated they do not have a backup system to ensure dish machine is sanitizing correctly. There was not additional information for the dish machine logs that were missing monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 2/11/25, at 3:09 PM, at the facility exit meeting, Surveyor shared the dish machine sanitizing concerns with Nursing Home Administrator (NHA) -A, Regional Nurse Consultant (RNC) -N and Director of Nurses Level of Harm - Minimal harm or (DON)-B. potential for actual harm 38829 Residents Affected - Many 2) Surveyor was provided a Dining, Organization, Staffing, and Service policy and procedure last reviewed 11/29/06. The policy documents: F. Sanitary conditions shall be maintained in the storage, preparation and distribution of food.

On 2/11/25, at 8:53 AM, Surveyor observed staff distributing the room breakfast trays. Surveyor observed

the tray cart with door left open. Surveyor observed that the hot cereal, cold cereal, and orange in a dish is not covered. Staff take a tray out of the cart and walk 2-3 rooms away from the cart.

On 2/11/25, at 12:40 PM, Surveyor observed the room lunch trays have an uncovered cookie and uncovered grated cheese on the trays.

On 2/11/25 at 2:19 PM, Surveyor interviewed Regional Food Service Director (RFSD)-Z and Food Service Director (FSD)-W together. Both confirmed that a lid covers the heated plate and then transferred to the covered cart for Resident rooms. The only side item that gets covered would be the soup which would get a disposable lid.

On 2/13/25 at 8:49 AM, Surveyor made observations of breakfast trays being delivered to Resident rooms.

The cart of breakfast trays is parked at the beginning of the hallway of Unit A. Certified Nursing Assistant (CNA)-FF is delivering the breakfast trays. Surveyor observed CNA-FF going 3 rooms down from the cart. Surveyor observed cereal and the fruit are not covered. CNA-FF delivered breakfast trays to rooms [ROOM NUMBERS].

On 2/13/25, at 8:51 AM, CNA-FF moved the cart to the center of the hallway, and served the first room on

the right(106). Side items on the tray were not covered.

On 2/13/25, at 8:56 AM, CNA-FF took room(108) tray out of the cart and walked it down to room [ROOM NUMBER] with milk on the tray with no items covered including the milk. Surveyor observed this was 3 rooms down from cart.

On 2/13/25, at 9:04 AM, CNA-FF took a tray out of the cart and crossed the hall to room [ROOM NUMBER]. Side items are not covered. CNA-FF placed the tray on top of the isolation cart, put a gown on and delivered

the tray.

On 2/13/25, at 9:19 AM, Surveyor observed CNA-CC carrying a tray all the way down to the last room on the right. CNA-CC informed Surveyor that CNA-CC got the tray from the dining room kitchenette because the Resident wanted the food to be hot. Surveyor observed the plate was covered, but the cereal and berries were not. Tea was covered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 525421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 2/13/25, at 10:05 AM, Surveyor spoke with RFSD-Z via telephone. RFSD-Z confirmed only the hot meal gets covered to keep the temperature. and goes directly into the covered cart. No other items are covered. Level of Harm - Minimal harm or RFSD-Z understands the concern that when the cart is parked at the beginning of the hallway and staff is potential for actual harm walking the Resident room trays down the hallway with uncovered items.

Residents Affected - Many On 2/13/25, at 3:04 PM, Surveyor shared the concern with Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A the concern that items are not covered on the Resident room trays and are delivered down the hallway 2-3 rooms away from the cart. Surveyor explained that food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor). NHA-A shared that the facility will be getting all new kitchen staff. No other information has been provided at this time.

On 2/17/25, at 8:59 AM, Surveyor observed Resident room breakfast trays being distributed. Surveyor observed the the tray cart at the beginning of the Unit A hallway by room [ROOM NUMBER]. CNA-FF 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 525421