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 38 of 99 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 39 of 99 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 40 of 99 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 41 of 99 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 42 of 99 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 43 of 99 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 44 of 99 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 45 of 99 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 46 of 99 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 47 of 99 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 48 of 99 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 49 of 99 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 50 of 99 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 51 of 99 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 52 of 99 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49435

Residents Affected - Few Based on observations, interview and record review, the facility did not ensure 2 (Resident R346 and Resident R23) of 2 residents reviewed for an indwelling catheter received the necessary services for monitoring of the indwelling catheter.

* Resident R346 has a physician's order and a care plan intervention to monitor and document catheter output three times a day. Facility staff did not document catheter output from 2/3/25 through 2/15/24.

* Resident R23 has a physician's order and a care plan intervention to monitor and document catheter output three times a day. Facility staff did not document catheter output from 11/1/24 through 2/15/24.

Findings include:

The facility policy with no date and titled, Standard indwelling Catheter Protocol documents: Goal-Patency will be maintained, and risk of infection will be minimized . [Certified Nursing Assistant (CNA)]- Provide perineal care am and pm shift and as needed. Keep drainage bag below level of bladder and off floor, tubing free of kinks, twists or pressure. Empty drainage bag and document output every shift in electronic record .

1.) Resident R346 was admitted to the facility on [DATE REDACTED] with diagnoses that includes cystitis, retention of urine and complicated urinary tract infection.

Resident R346's Admission Minimum Data Set assessment dated [DATE REDACTED] documents Resident R346 is moderately cognitively impaired. Resident R346 has a urinary catheter.

Resident R346's urinary catheter care area assessment (CAA) dated 2/10/225 documents, in part: CAA triggered due to resident having a Foley Catheter due to urinary retention. [Resident R346] Is at risk for . urinary infection . Will proceed to care plan to continue with current toileting plan, monitor and evaluate effectiveness, minimize risks.

Resident R346's Indwelling Catheter/retention uropathy care plan dated 2/3/25, includes the following pertinent interventions: The resident has Indwelling 16fr [French], 10 cc [cubic centimeters]. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Enhanced Barrier Precaution. Monitor and document intake and output as per facility policy.

Resident R346's MD order dated 2/3/25 documents, Indwelling Foley catheter 16fr with 10 cc balloon for urinary retention.

Resident R346's MD order dated 2/3/25 documents, Monitor Catheter Output three times a day.

Resident R346's Treatment Administration Record (TAR) for the month of February. Surveyor noted that Resident R346's catheter output was not documented by facility staff from 2/3/25 through 2/15/25. Facility staff started documenting catheter output during the day shift on 2/16/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 99 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 0690 On 2/17/25 at 7:48 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-LL. Surveyor asked how often a catheter bag should be emptied. CNA-LL stated the catheter bag should be emptied every shift. Level of Harm - Minimal harm or Surveyor asked if the output is documented within the electronic medical record. (CNA)-LL stated it should potential for actual harm be documented every shift.

Residents Affected - Few On 2/17/25 at 7:49 AM, Surveyor interviewed CNA-D. Surveyor asked how often a catheter bag should be emptied. CNA-D indicated the catheter bag should be emptied every shift. Surveyor asked where the output is documented. CNA-D stated that CNA-D tells the nurse the output and the nurse documents the output in

the electronic medical record.

On 2/17/25 at 7:54 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-MM Surveyor asked how often

a catheter bag should be emptied. LPN-MM stated that it should be emptied every shift. Surveyor asked where the output should be documented. LPN-MM stated it is documented in the TAR. LPN-MM stated that CNAs will empty the catheter bag and then tell the nurse what the output was for that shift. The nurse will enter total output for that shift in the TAR.

On 2/17/25 at 9:05 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-G. Surveyor asked how often a catheter bag should be emptied. ADON-G stated every shift. Surveyor asked where the output is documented. ADON-G stated it is documented in the TAR.

On 2/17/25 at 10:08 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked how often a catheter bag should be emptied and output documented. DON-B indicated it should be completed and documented every shift. Surveyor asked where catheter output documentation is located. DON-B stated in

the Medication Administration Record (MAR) or TAR. Surveyor asked if Resident R346 had documentation of catheter output from 2/3/25 through 2/15/25. DON-B indicated that there is no documentation of catheter output prior to 2/16/25.

On 2/17/25 at 12:08 PM Surveyor informed Nursing Home Administrator (NHA)-A and Regional Nurse Consultant-N of the concern that Resident R346 has a care plan intervention and a physician order to monitor catheter output three times a day and that facility staff did not document catheter output from 2/3/25 through 2/15/24.

No additional information was given as to why the facility did not ensure that Resident R346 received the necessary services for monitoring of the indwelling catheter.

20483

2.) Resident R23's diagnoses includes obstructive & reflux uropathy and neuromuscular dysfunction of the bladder. Resident R23 is receiving hospice services.

Resident R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 is checked for an indwelling catheter.

Resident R23's urinary incontinence and indwelling catheter CAA (care area assessment) dated 11/11/24 documents under the analysis of findings for nature of problem/condition: neurogenic bladder obstructive urop (uropathy) foley cath (catheter) retention. Under the care plan considerations section it documents: Proceed to plan of care. Maintain Foley cath-cath places at risk for infection. Goal for no complications/infections r/t (related to) cath.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 99 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 0690 Resident R23's indwelling catheter care plan initiated 11/1/24 & revised 11/11/24 includes an intervention of monitor and document intake and output as per facility policy. This intervention is documented as initiated & revised Level of Harm - Minimal harm or on 11/1/24. potential for actual harm Resident R23's physician order dated 11/1/24 documents monitor catheter output three times a day. Residents Affected - Few

On 2/10/25, at 9:59 a.m., Surveyor observed Resident R23 sitting in a wheelchair in Resident R23's room. Surveyor observed a urinary collection bag under Resident R23's wheelchair.

On 2/10/25, at 3:43 p.m., Surveyor observed Resident R23 sitting in a wheelchair in Resident R23's room. The urinary collection bag was observed on the right side of Resident R23's wheelchair.

On 2/11/25, at 12:59 p.m., Surveyor observed Resident R23 sitting in a wheelchair with Resident R23's lunch tray in front of Resident R23 on the over bed table. Resident R23's urinary collection bag is under the Resident R23's wheelchair.

On 2/11/25, at 11:35 a.m., Surveyor entered Resident R23's room with Certified Nursing Assistant (CNA)-K. CNA-K washed her hands, placed gloves on, and informed Resident R23 she was going to empty her catheter. CNA-K emptied 200 cc (cubic centimeters) of urine into a collection basin, wiped the end of the spicket with an alcohol pad, and placed the collection bag under Resident R23's wheelchair. CNA-K emptied the urine in the toilet, rinsed the collection basin, removed her gloves, and washed her hands.

On 2/13/25, at 7:27 a.m., Surveyor observed Resident R23 in bed on her back. Surveyor observed Resident R23's urinary collection bag resting directly on the blue mat.

On 2/13/25, at 11:33 a.m. Surveyor observed Resident R23 sitting in a wheelchair with her legs extended. Surveyor observed the urinary collection bag is in a black bag under Resident R23's wheelchair.

On 2/17/25, at 7:18 a.m., Surveyor reviewed Resident R23's TARs (Treatment Administration Record). Surveyor noted

the TARs include Monitor Catheter Output three times a day with a start date of 11/1/24. Times listed are 0800 (8:00 a.m.), 1300 (1:00 p.m.) and 1800 (6:00 p.m.). Surveyor noted Resident R23's November 2024, December 2024, and January 2025 TARs does not have any urinary output documented during these months. The February 2025 TAR does not have any output documented until 2/16/25.

On 2/17/25, at 7:34 a.m., Surveyor reviewed Resident R23's nurses notes for Resident R23's urinary output and noted only the following nurses notes:

Resident R23's nurses note dated 11/26/24, at 20:34 (8:34 p.m.) written by Licensed Practical Nurse (LPN)-E documents: Resident had 600 ml (milliliter) urine output.

Resident R23's nurses note dated 2/8/25, at 21:56 (9:56 p.m.) written by LPN-E documents: Foley output was 100 cc (cubic centimeter).

On 2/17/25, at 10:43 a.m., Surveyor asked LPN-UU how they monitor urinary output for residents who have

an indwelling catheter. LPN-UU informed Surveyor they monitor the measurements of what is the urine bag. Surveyor asked if this is documented. LPN-UU informed Surveyor the amount is documented in PCC (pointclickcare). LPN-UU informed Surveyor any resident who has a catheter has output and then they go from there.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 99 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 0690 On 2/17/25, at 10:46 a.m., Surveyor asked Registered Nurse Supervisor/Wound Nurse-I if a resident has an indwelling urinary catheter do they monitor output. Registered Nurse Supervisor/Wound Nurse-I informed Level of Harm - Minimal harm or Surveyor it's suppose to be done every shift. Surveyor asked Registered Nurse Supervisor/Wound Nurse-I if potential for actual harm she knew why Resident R23's output wasn't being monitored until 2/16/25. Registered Nurse Supervisor/Wound Nurse-I replied no I don't she's always had a catheter. Surveyor informed Registered Nurse Residents Affected - Few Supervisor/Wound Nurse-I Surveyor had reviewed Resident R23's TAR and there is no documentation of Resident R23's output from date of admission until 2/16/25. Registered Nurse Supervisor/Wound Nurse-I replied I don't know what to say about that.

On 2/17/25, at 1:48 p.m., Surveyor asked Director of Nursing (DON)-B if a physician orders urine output monitoring every shift what is the expectation. DON-B informed Surveyor for the nurses to enter the output of

the urine. Surveyor asked DON-B if she was aware there has not been any output monitoring of Resident R23's urine until 2/16/25 with the exception of a couple nurses notes. DON-B informed Surveyor she did not realize this.

No additional information was provided as to why Resident R23's urinary output was not being monitored according to physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 99 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 20483 potential for actual harm Based on observation, interview, and record review the facility did not provide the necessary respiratory care Residents Affected - Few and services for 1 (Resident R23) of 2 residents receiving oxygen therapy.

* Resident R23's oxygen tubing was dated 12/7/24 and was not changed weekly according to Resident R23's physician orders.

Findings include:

The facility's policy with no date and titled, Standard Respiratory Protocol documents under the RN (Registered Nurse) section: Replace DME (durable medical equipment) as ordered.

Resident R23's diagnoses includes interstitial pulmonary disease, heart failure, and chronic respiratory failure with hypoxia.

Resident R23's physician orders dated 11/1/24 documents Change oxygen tubing -Date Tubing every night shift every 7 days(s).

Resident R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 documents that Resident R23 requires oxygen.

On 2/10/25, at 11:37 a.m., Surveyor observed Resident R23 sitting in a wheelchair receiving oxygen via a nasal cannula at 2 liters per minute. Surveyor observed the oxygen tubing to be dated 12/7/24.

On 2/10/25, at 3:43 p.m., Surveyor observed Resident R23 sitting in a wheelchair in Resident R23's room receiving oxygen via nasal cannula at 2 liters per minute. Surveyor observed Resident R23's oxygen tubing dated 12/7/24.

On 2/11/25, at 7:14 a.m., Surveyor observed Resident R23 in bed on her back receiving oxygen via nasal cannula at 2 liters per minute. Surveyor observed the oxygen tubing dated 12/7/24.

On 2/11/25, at 12:59 p.m., Surveyor observed Resident R23 sitting in a wheelchair with Resident R23's lunch tray on the over bed table in front of Resident R23. Resident R23 was observed receiving oxygen via nasal cannula at 2 liters per minute. The oxygen tubing is dated 12/7/24.

On 2/11/25, at 2:42 p.m., Surveyor observed Resident R23 sleeping in bed on her back. Surveyor observed Resident R23 is receiving oxygen via nasal cannula at 2 liters per minute. Surveyor observed the oxygen tubing is dated 12/7/24.

On 2/13/25, at 7:27 a.m., Surveyor observed Resident R23 in bed on her back receiving oxygen via nasal cannula at 2 liters. Surveyor observed the oxygen tubing is dated 12/7/24. Certified Nursing Assistant/Med Tech (CNA/Med Tech)-KK entered Resident R23's room to obtain Resident R23's blood sugar. Surveyor asked CNA/Med Tech-KK how often oxygen tubing is changed. CNA/Med Tech-KK replied the nurses do that at night. Surveyor informed CNA/Med Tech-KK Resident R23's oxygen tubing is dated 12/7/24. CNA/Med Tech-KK replied that's not good. CNA/Med Tech-KK informed Surveyor she thinks it's changed weekly but can check and let Surveyor know.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 99 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 0695 On 2/13/25, at 7:32 a.m., Surveyor asked Director of Nursing (DON)-B how often oxygen tubing is changed. DON-B replied weekly. Surveyor asked DON-B if Surveyor could show her the date on Resident R23's oxygen tubing. Level of Harm - Minimal harm or Surveyor accompanied DON-B into Resident R23's room and showed DON-B Resident R23's oxygen tubing is dated 12/7/24. potential for actual harm

On 2/13/25, at 7:33 a.m., CNA/Med Tech-KK informed Surveyor DON-B is going to change the oxygen Residents Affected - Few tubing.

On 2/13/25, at 11:33 a.m., Surveyor observed Resident R23 sitting in a wheelchair with her legs extended and appears to be sleeping. Resident R23 is receiving oxygen via nasal cannula at 2 liters per minute. Surveyor observed

the oxygen tubing is now dated 2/13/25.

No additional information was provided as to why Resident R23's oxygen tubing was not changed weekly according to physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 99 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42037 potential for actual harm Based on interview and record review, the facility did not provide dialysis services consistent with Residents Affected - Few professional standards of practice for 1 (Resident R39) of 1 Residents reviewed for dialysis.

* Resident R39 receives dialysis three times per week. Resident R39's dialysis center communication records are not being consistently completed by Facility nurses.

Findings include:

1. Resident R39 was admitted to the facility on [DATE REDACTED] with diagnoses of Protein Calorie Malnutrition, End Stage Renal Disease and Dependence on Renal Dialysis.

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

Resident R39's care plan with an initiation date of 7/12/24 documents: Alteration in nutrition poor oral intake, abnormal labs, gradual weight loss, decline in chewing ability R/T (related to) ESRD (End Stage Renal Disease, edentulous (without teeth), Anemia (low iron level in blood, weakness A/E/B (As Evidenced By): new dx: PCM (Plasma Cell Myeloma), beginning IDPN (Intradialytic Parenteral Nutrition), Dialysis 3 x (times) a week, intake < (less than) 25 %, Mech (mechanical) soft diet, Supplements. Resident R39's comprehensive care plan documents the following interventions: .Send Dialysis binder with resident (Resident R39) for communication from Dialysis nurse- check binder on dialysis days .one time a day every Mon, Wed, Fri for HD (Hemodialysis) .

On 2/10/25, Surveyor requested Resident R39's dialysis communication binder from RN (Registered Nurse)-GGG. Surveyor asked RN-GGG if there should dialysis communication forms completed by facility nursing staff on each day that Resident R39 attends dialysis. RN-GGG responded that RN-GGG is newly employed by the facility but it would be RN-GGG's understanding that every time Resident R39 goes to dialysis that there should be a dialysis communication form completed. RN-GGG confirmed with Surveyor that Resident R39 is the only resident currently residing at the facility who receives dialysis.

On 2/11/25, Surveyor requested copies from NHA (Nursing Home Administrator)-A of Resident R39's dialysis communication forms from their admitted [DATE REDACTED] to 2/11/25. Surveyor reviewed Resident R39's dialysis communication forms provided by the facility. Surveyor noted facility did not fully complete Resident R39's dialysis communication forms on the following dates: 7/15/24, 8/16/24, 9/4/24, 9/30/34, 10/14/24, 10/28/24, 11/1/24, 2/3/25 and 2/5/25. From 11/5/24 to 1/21/25, Surveyor did not note any of Resident R39's dialysis communication to be available for review.

On 2/11/25 at 3:39 PM, Surveyor shared concern with NHA-A and DON (Director of Nursing)-B related to Resident R39's multiple incomplete and missing dialysis communication records on 7/15/24, 8/16/24, 9/4/24, 9/30/34, 10/14/24, 10/28/24, 11/1/24, 11/5/24 to 1/21/25, 2/3/25 and 2/5/25.

No additional information was provided as to why the facility did not provide dialysis services consistent with professional standards of practice for Resident R39.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 99 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 60 of 99 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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 42037

Residents Affected - Many Based on review of daily staff postings, staffing schedules, and interview, the facility did not use the services of a RN (Registered Nurse) for at least 8 consecutive hours a day, 7 days a week.

* On multiple dates, there was no RN who worked at the facility for 8 consecutive hours.

This deficient practice has the potential to affect 49 of 49 residents residing in the building.

Findings include:

1.) 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 indicate the presence of an RN in the facility on the following dates:

July 2024: July 4, 5, 9, 11, 18, 20, 24, 25, 26, 27, 28.

August 2024: August 1, 2, 5, 6, 15, 16, 19, 20, 21, 25, 29, 30.

September 2024: September 3, 8, 12, 13, 16, 21, 22, 26, 30.

January 2025: January 13, 18, 19, 20, 23, 30.

February 2025: February 3.

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 the facility was were aware that schedules that were reviewed by Surveyors for Quarter 4 (July 1st -September 30th, 2024) and 1/20/25-2/10/25 indicated that there was not

an RN in the facility for at least 8 consecutive hours for the above dates.

Scheduler-HHH told Surveyor that the faciliy was aware that there was a problem finding enough RNs to work for a stretch of time at the facility. Scheduler-HHH added that most days, DON-B is at the facility and can act as the covering RN. Surveyor asked Scheduler-HHH if DON-B is acting as the covering RN on weekends. Scheduler-HHH responded that they are aware of DON-B coming in some weekends to act as covering RN but that it may not be reflected on all of the facility's daily schedules.

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 indicating on the above dates that an RN was in the facility for a consecutive 8 hour tour of duty.

No additional information was provided as to why the facility did not ensure that an RN (Registered Nurse) was on duty for at least 8 consecutive hours a day, 7 days a week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 99 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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 42037 minimal harm Based on observation, interview, and record review, the facility did not ensure that the daily nurse staff Residents Affected - Many posting included all required information accurately. This deficient practice has the potential to affect a pattern of all 39 residents residing in the facility.

The facility's nurse staff posting did not accurately reflect the correct number of staff members on each daily nurse staff posting.

Findings include:

On 1/25/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting and schedules for 1/20/25-2/10/25. Surveyor reviewed facility's nursing schedules and nurse staff postings. Surveyor noted the facility did not accurately include the proper number of staff members on each nurse staff posting for Quarter 4 and 1/20/25-2/10/25 including CNAs (Certified Nursing Assistants), Medication Technicians, LPNs (Licensed Practical Nurses) and RNs (Registered Nurses).

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 are inaccuracies within the facility's nurse staff postings for Quarter 4 (July 1st -September 30th, 2024) from 1/20/25-2/10/25 to include the proper number of CNAs, Medication Technicians, LPNs and RNs that are working at the facility for each shift. Scheduler-HHH told Surveyor that they were not aware of any issues with the nurse staff postings.

On 1/23/25, at 2:40 PM, Surveyor conducted an interview with Nursing Home Administrator (NHA)-A. Surveyor shared concern that the facility's nurse staff postings inaccuracies within the facility's nurse staff postings for Quarter 4 (July 1st -September 30th, 2024) from 1/20/25-2/10/25 did not include the proper number of CNAs, Medication Technicians, LPNs and RNs that are working at the facility for each shift.

The facility did not provide any additional as to why the facility did not ensure that the daily nurse staff posting included all required information accurately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 99 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42037 potential for actual harm Based on interview and record review, the facility did not ensure adequate monitoring for adverse reactions Residents Affected - Few of high-risk medications for 1 (Resident R7) of 6 residents reviewed for unnecessary medications in accordance with standards of practice.

*Resident R7 has physician's order for Warfarin (an anticoagulant) for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. The facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant.

1.) Resident R7 was admitted to the facility on [DATE REDACTED] with diagnoses that includes Atrial Fibrillation, Cerebral Infarction and Hyperlipidemia.

Resident R7's Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 12/23/2024 indicates that Resident R7 received an Anticoagulant medication during the assessment period.

Surveyor reviewed Resident R7's electronic medical record and could not locate a person-centered care plan to monitor for adverse side effects related to the use of an anticoagulant and diuretic.

Resident R7's medical record was reviewed including physician orders, MARs (Medication Administration Records) TARs (Treatment Administration Records) and comprehensive care plans.

Resident R7's physicians orders document the following: .Warfarin Sodium oral tablet 2 mgs (milligrams), give 2 mg by mouth at bedtime every Tuesday, Thursday, Saturday and Sunday .Warfarin Sodium oral tablet 2 mg, Give 4 mg by mouth at bedtime every Monday, Wednesday and Friday . Surveyor reviewed Resident R7's MAR from June 2024 to February 2024. Resident R7 has been receiving Warfarin Sodium on a scheduled basis since June 2024.

Surveyor reviewed Resident R7's comprehensive care plan. Resident R7's comprehensive care plan with an initiation date of 6/24/24 documents the following: The resident (Resident R7) is on anticoagulant therapy (Warfarin) r/t (related to) Atrial Fibrillation. Resident R7's care plan interventions include the following: .Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness Q (every) shift .

Surveyor reviewed Resident R7's MARs and TARs for June 2024-February 2025. Surveyor was unable to located any medication monitoring related to Resident R7's use of the anticoagulant medication Warfarin.

On 2/12/25 at 2:15 PM, Surveyor conducted interview with DON (Director of Nursing)-B. Surveyor asked DON-B how often a resident receiving anticoagulant therapy such as Warfarin, should be monitored for medication side effects or adverse reactions. DON-B responded that residents receiving Warfarin should be monitored for side effects every shift by nursing staff.

On 2/12/25 at 3:30 PM at the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A and DON-B that Surveyor was unable to locate any medication monitoring for Resident R7's use of Warfarin, an anticoagulant medication, in their medical record. DON-B stated that they would look into this matter further.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 99 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 0757 On 2/13/25 at 8:10 AM, Surveyor conducted a follow up interview with DON-B. Surveyor confirmed with DON-B that Resident R7 does not have any documented medication monitoring for their use of Warfarin. Level of Harm - Minimal harm or potential for actual harm No additional information was provided by facility at this time.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 99 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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38829

Residents Affected - Few Based on observation, interview and record review, the facility did not provide 3 (Resident R196, Resident R197, and Resident R347) of 3 residents reviewed for dietary services, with food accommodations and preferences as listed on the Resident's meal tickets.

* Resident R196 meal ticket states no oatmeal and received oatmeal on 2/11/25 and 2/12/25. Resident R196 did not received

the berries for breakfast on 2/13/25.

* Resident R197's meal ticket states dislikes eggs but received denver eggs on 2/11/25 for breakfast.

*On 2/11/25, residents received a peanut butter cookie instead of the frosted pumpkin bar listed on the posted menu. On 2/12/25, the Residents received beef barley soup instead of french onion soup listed on the posted menu.

* Resident R347 did not received a banana per meal ticket on 2/13/25.

Findings Include:

Surveyor reviewed the facility's dining policies and procedures. The undated Meal Identification policy documents:

Policy:

.A electronic meal identification and food preferences slip is used to properly identify each individual's needs and desires for food.

Procedure:

1. The food service manager visits a newly admitted individual to obtain food and beverage preferences, dislikes and food allergies/intolerances before a electronic meal identification and preference card (meal ID card) is written.

2. A temporary meal ID card containing the individual's name, room number and diet order may be used until

a permanent one is prepared (usually for the first meal or two).

3. The electronic meal ID includes the name of the individual, room number, diet order, beverage preferences, food dislikes and any other specific diet information. Food allergies should be written in red, or printed boldly to call attention to them.

4. Meal ID are used during meal service to ensure the correct diet is being served and food preferences are honored.

5. Meal ID are placed on corresponding meals to ensure delivery to the correct individual.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 99 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 0806 7. The food service manager/RD is responsible for keeping ID up-to-date.

Level of Harm - Minimal harm or Note: If computerized paper meal ID cards are used, they may be left on the tray for service. Staff may use potential for actual harm these paper tray cards to note changes in preferences, food intake percentages and other pertinent information to send back to the food service department. Residents Affected - Few

The undated Diet Order policy and procedure documents:

Policy:

.The food service department must receive a completed diet order as soon as possible after admission or following a diet order change.

Procedure:

1. The nursing staff sends the diet order(per physician's orders) to the food service department as soon as possible after admission or change(preferably within 1 to 2 hours), using the Diet Order Form.

6. Diet orders are file in the food service department.

7. Meal identification cards are adjusted accordingly.

The Meal and Nourishment policy and procedure last revised 6/21/06 documents:

.Procedure: A. Each Resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with Resident needs, preferences, requests, and plan of care.

1.) Resident R196 was admitted to the facility on [DATE REDACTED] with diagnoses of Hypothyroidism, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, Essential Hypertension, and Displaced Comminuted Fracture of Shaft of Right Femur.

Resident R196's Admission Minimum Data Set(MDS) dated [DATE REDACTED] is was in the process of being completed. The Brief Interview for Mental Status(BIMS) has been completed and the score was 15, indicating Resident R196 is cognitively intact for daily decision making. No other MDS sections are completed at the time of the survey.

On 2/10/25, at 10:10 AM, Surveyor spoke with Resident R196 who stated Resident R196 needs to see the dietitian. Resident R196 has not been asked when admitted to the facility what Resident R196's preferences are or choice of cereal. Resident R196 received oatmeal and does not like oatmeal.

On 2/10/25, at 1:16 PM, Surveyor observed Resident R196's lunch tray. Resident R196 is upset because Resident R196 received a hamburger on bun, but the menu states kiebesa and was anticipating the kiebesa. Certified Nursing Assistant (CNA)-EE explained to Resident R196 that the hamburger is considered heart healthy per Resident R196's diet but will go get the kiebesa for Resident R196.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 99 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 0806 On 2/11/25, at 8:53 AM, Resident R196 informed Surveyor that Resident R196 spoke with the dietitian last night and informed Registered Dietitian (RD)-DD that Resident R196 does not like oatmeal. Resident R196 provided RD-DD with likes and dislikes. Level of Harm - Minimal harm or Resident R196 wants dry cereal with milk for breakfast. potential for actual harm

On 2/11/25, at 8:58 AM, Surveyor observed Resident R196 received oatmeal on Resident R196's breakfast tray. Resident R196's meal Residents Affected - Few ticket states dislikes oatmeal. Surveyor received permission from Resident R196 to keep Resident R196's breakfast meal ticket.

On 2/13/25, at 8:41 AM, Resident R196 informed Surveyor Resident R196 received oatmeal on 2/12/24. Surveyor observed Resident R196's meal ticket which states: likes cold cereal, dislikes oatmeal. Instructions: cold cereal daily with milk.

This was all highlighted. Resident R196 had to send the oatmeal back. Surveyor received permission from Resident R196 to keep Resident R196's breakfast meal ticket.

O 2/13/25, at 9:00 AM, Surveyor observed Resident R196 tell CNA-FF that Resident R196 did not get the fruit(berries) so CNA-FF went back to the kitchen with Resident R196's meal ticket, came back to Resident R196's room and told Resident R196 they would be getting the berries for Resident R196.

2.) Resident R197 was admitted to the facility on [DATE REDACTED] with diagnoses of Unspecified Fracture of Left Patella, Dysphagia, Unspecified Asthma, and Essential Hypertension.

Resident R197's Admission MDS dated [DATE REDACTED] documents Resident R197's BIMS score of 15, indicating Resident R197 is cognitively intact for daily decision making. No other sections are completed.

On 2/11/25, at 8:49 AM, Surveyor observed Resident R197's breakfast tray which had denver eggs on it. Resident R197's breakfast meal ticket states dislikes eggs. Surveyor received permission from Resident R197 to keep Resident R197's breakfast meal ticket.

3.) On 2/11/25, at 1:00 PM, Surveyor observed that all residents received a cookie on their trays instead of

the posted frosted pumpkin bar.

On 2/11/25, at 10:02 AM, Surveyor interviewed RD-DD. RD-DD informed Surveyor that RD-DD is full time at

the facility and is responsible for getting likes/dislikes, preferences from the Residents. RD-DD will meet with Residents within 24-48 hours to evaluate. If a Resident comes in on a Friday, RD-DD will evaluate on Monday. RD-DD get meal tickets printed right away. As soon as RD evaluates, gets likes/dislikes/preferences will print the ticket. RD-DD stated that dietary should be checking the tickets. If a Resident does not like oatmeal, cold cereal bins are located on the counter in the dining room. The CNA is supposed to ask what cold cereal a Resident wants and fill the bowl up. Preferences show up on all 3 meals tickets.

On 2/11/25, at 2:19 PM, Surveyor interviewed both Regional Food Service Director (RFSD)-Z and Food Service Director (FSD)-W. FSD-W explained the process is that the meal ticket is located on the Resident tray. The dietary aide tells the dietary aide serving the food, the correct diet and preferences, and is placed in

the cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 99 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 0806 The dietary aide reading the meal ticket is expected to be checking the tray that the Resident received the preferred items. If there is a menu change, RD-DD informs the Residents. If a Resident dislikes eggs should Level of Harm - Minimal harm or they have never received the denver scrambled eggs. If a Resident dislikes oatmeal, they should not have potential for actual harm received oatmeal on their tray. The dietary staff should have read the ticket and offered an alternative.

Residents Affected - Few On 2/13/25, at 10:05 AM, Surveyor interviewed RFSD-Z via telephone. Surveyor shared the concern with RFSD-Z that Residents are not receiving food items based on their meal tickets. RFSD-Z stated someone is not doing their job. Surveyor interviewed RD-DD at this time. RD-DD informed Surveyor that RD-DD goes over the menu for the next week to make sure the facility can get food items in. RD-DD stated that the facility can't even get frosted pumpkin bars and not sure why the frosted pumpkin bar was on the menu. RD-DD then informed Surveyor that on 2/12/25, the Residents received beef barley instead of french onion soup. RD-DD and Surveyor discussed that items are changing without informing the Resident. RD-DD stated that if RD-DD knows ahead of time, RD-DD can change the ticket. RD-DD stated the cookie was peanutbutter and luckily no one has a peanut allergy. RD-DD provided documentation that there have been 8 items substituted since 7/28/24.

On 2/13/25, at 3:04 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that Resident R196 and Resident R197 have not been receiving preferences as documented on Resident R196, and Resident R197's meal tickets.

No further information was provided by the facility.

49435

4.) Resident R347 was admitted to the facility on [DATE REDACTED] with diagnosis that include stroke, weakness and vascular dementia.

Resident R347 Admission Minimum Data Set assessment dated [DATE REDACTED] documents Resident R347 is severely cognitively impaired. Resident R347 has an activated Power of Attorney, (POA)-GG.

On 2/10/25 at 12:15 PM, Surveyor interviewed POA-GG. POA-GG informed Surveyor that Resident R347's meal tray ticket does not always match what is served on Resident R347's tray. POA-GG stated that there are times when fruits or vegetables are missing, and POA-GG will approach staff to get the missing item or Resident R347 will have to go without it. POA-GG stated that fruits and vegetables are important to Resident R347.

On 2/13/25 at 10:21 AM, Surveyor observed Resident R347 in Resident R347's room with POA-GG. Resident R347 was eating breakfast. Surveyor asked POA-GG if Resident R347 received everything Resident R347 wanted and preferred on Resident R347's breakfast tray. POA-GG indicated that Resident R347 did not receive a banana and wanted a banana.

Surveyor reviewed Resident R347's breakfast tray meal ticket dated 2/13/2025 which documents: Choice of Juice, [NAME] Krispies or oatmeal, [Ground] Sausage gravy, Biscuit (Must be covered in gravy), Banana, Milk. Surveyor noted that everything, except the banana, was on Resident R347's breakfast tray on 2/13/25.

On 2/13/25 at 10:25 AM, Surveyor informed Licensed Practical Nurse (LPN)-HH that Resident R347 did not receive a banana on Resident R347's breakfast tray and Resident R347 still preferred to receive the banana. LPN-HH indicated that LPN-HH will get a banana for Resident R347. Surveyor observed LPN-HH enter Resident R347's room to give Resident R347 a medication. LPN-HH spoke to Resident R347 and POA-GG about getting Resident R347 a banana.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 99 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 0806 On 2/13/25 at 1:43 PM, Surveyor observed Resident R347 and POA-GG in Resident R347's room. Surveyor asked if Resident R347 received the banana that was requested earlier in the day. POA-GG stated that Resident R347 did not receive a Level of Harm - Minimal harm or banana. potential for actual harm

On 2/13/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing Residents Affected - Few (DON)-B about Resident R347 not getting Resident R347's choice of banana on Resident R347's breakfast meal tray and after requesting it again, as of 1:43 PM, Resident R347 had still not received the requested banana.

No additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 99 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 70 of 99 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 71 of 99 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 72 of 99 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 73 of 99 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 51016 potential for actual harm Based on observations, interviews, and record review, the facility did not establish and maintain an infection Residents Affected - Many prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

* The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern. No interventions were implemented along with tracking and measurement documentation to show effectiveness of interventions the facility implemented to prevent

the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment.

*The facilities infection control program does not use baseline infection rates to analyze prevalent infections

in the facility. The facility's infection control program did not comprehensively track interventions and analyze outcomes for 2 outbreaks in the facility. The facility assessment does not address how the combined role of Assistant Director of Nursing/Infection Preventionist are delineated.

* Resident R346 was on enhanced Barrier precautions. Staff did not utilize proper hand hygiene when entering or leaving room.

This deficient practice has the potential to affect all 49 residents residing in the facility.

Findings include:

Facility policy titled: Water management program Legionella. Reviewed 12/13/23.

I. Policy: Entity Shall Identify and manage risks arising from exposure to Legionella bacteria in water systems. The standards identified below will be followed in order to prevent and control Legionnaires Disease and outbreaks.

II. Procedure:

A. Water management team.

i. Entities water management program is overseen by the Water Management team.

ii. The team consists of at a minimum. The Executive Director, Environmental Services Lead, and Infection Preventionist.

iii. Other members of the team may include Medical Director, Director of Quality and Risk Management Contractual Microbiologist Consultant, Industrial Hygienist, local water department representative, water maintenance contractor representative.

B. Facility risk assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 99 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 0880 i. Legionella environmental assessment will be conducted by the water management team annually and periodically as changes in the environment conditions dictate. Level of Harm - Minimal harm or potential for actual harm ii. The following will be included within the assessment.

Residents Affected - Many 1. Water flow mapping diagrams describing the building, water systems and areas where Legionella could be present.

2. Areas of risk of stagnation, temperature becoming ideal for growth, devices with standing water, decorative fountains, etcetera.

iii. Water Management team will review the assessment within Quality Assurance and Process Improvement QAPI team annually.

C. Monitoring.

i. The water management team will be responsible for monitoring risk and identifying potential cases or breaches of control measures of concern.

ii. If facility is a municipality, said water department will monitor water parameters, residual disinfectant, temperature, PH.

iii. If facility is rural and on. A well system. Facility will monitor water parameters following CDC guidelines. Facility will monitor temperatures of hot water and visually check for biofilm, scale, build up, etcetera.

iv. All positive results of Legionella are reported to the local health department and the positive device is removed from service.

v. Areas of the water system found outside of normal limits will be flushed and serviced.

vi. If rooms are closed due to low census or put out of use, a routine process will be implemented to run faucets, showers and to flush toilets.

vii. Documentation will be retained.

viii. Corrective actions taken when control limits are not maintained will be documented.

D. Water management plan.

i. The water management plan will be reviewed annually or more often. As indicated.

E. Contingency response

i. If there is an implication of an outbreak of Legionellosis, decontamination of the hot water system may be necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 99 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 0880 ii. Based on the findings, Water Management Team or designee will reevaluate the disinfection process and make appropriate corrections. Thermal shock or shock chlorination methods of decontamination for the hot Level of Harm - Minimal harm or water system may be used. potential for actual harm iii. Entity shall flush dead legs, water heaters and plumbing fixtures with chlorine. Residents Affected - Many iv. If a water main break occurs, the main water valves will be closed, and the water emergency plan will be activated.

v. For potable water systems that were open for repair, other construction or subjected 2. Water pressure changes associated with construction. It is recommended that at a minimum the systems be thoroughly flushed.

Facility policy titled: Infection prevention and control program.

I. Policy: to prevent the development and transmission of disease and infection, the organization will follow

the infection prevention and control program procedures below,

II. Procedure:

1. prevention and surveillance the facility will:

i. Perform surveillance and investigation to prevent, to the extent possible, the onset and spread of infection.

ii. Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions.

iii. Source. Control measures may be initiated per facility source control protocol.

iv. Use records of symptom onset or antibiotic start, including but not limited to electronic medical record capabilities. Line lists for individuals and changes of condition, 24-hour reports to monitor for trends and improve its infection control processes and outcomes by taking corrective actions as indicated

v. Utilize hand hygiene practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross contamination and.

vi. Properly store, handle, process, and transport linens to minimize contamination.

2. Identification.

i. Standard and transmission-based precautions are to be followed to prevent spread of infections. Use the Center for Disease Control Guideline for Isolation Precautions to determine precautions.

ii. The isolation should be the least restrictive possible for the individual under the circumstances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 99 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 0880 iii. Staff will follow McGeer's criteria for infection identification.

Level of Harm - Minimal harm or 3. Reporting potential for actual harm i. All staff and individual infections will be reported to the infection preventionist or designee. Residents Affected - Many ii. The facility will report to the public health department according to the CDC and state guidelines.

4. Investigating.

i. Trends and patterns will be discussed with the Quality Assurance Performance Improvement Committee. Process improvement projects will be chartered and managed around identified opportunities for improvement. Resulting in countermeasures.

5. Controlling infections and communicable diseases

i. The organization will follow CDC, State of Wisconsin and or public health guidelines for identification of and monitoring of outbreak.

ii. Signage will be posted per current CDC recommendations.

6. Education

i. All staff will receive mandatory education training about infection control upon hire and annually.

ii. The IP will maintain current knowledge in the field of infectious disease and epidemiology through training provided through the CDC in collaboration with Centers for Medicare and Medicaid CMS.

Facility policy titled: Enhanced Barrier Precautions. Reviewed 2/6/25

I. Policy: will promote decreased transmission of Centers for Disease Control CDC targeted and epidemiologically important multidrug resistant organisms. MDRO by utilizing enhanced barrier precautions EBP.

II. Procedure.:

a. The infection prevention and control program establishes Enhanced barrier precautions EBP to reduce transmission of multidrug resistant organisms utilizing targeted gown and glove use during high contact resident care activities.

b. EBP are used in conjunction with Standard Precautions and expand the use of PPE to donning of gloves and gown during high contact resident care activities. That provide opportunities for transmission of MDRO to staff hands and clothing.

c. EBPR indicated for residents with any of the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 99 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 0880 i. Infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply.

Level of Harm - Minimal harm or ii. Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized potential for actual harm with a MDR O.

Residents Affected - Many 1. Wound care is included as a high contact resident care activity and is generally defined as the care of any skin opening and requiring a dressing. However, the intent of EBP is to focus on resident with higher risk of acquiring an MDRO / over a long period of time. This includes resident with chronic wounds, not those with only shorter lasting wounds such as skin breaks or skin tears covered with Band-Aid or similar dressing. Examples of chronic wound include, but are not limited to, pressure ulcers. Diabetic foot ulcers and chronic venous stasis ulcers

2. Indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheostomies. A peripheral intravenous line, not a peripherally inserted central catheter, is not considered

an indwelling medical device for the purposes of EBP.

d. Table one in attachment QSO. Dash 24-08-NH enhanced barrier precautions in nursing homes Details Implementing contact versus enhanced barrier precautions. MDROs.

e. For residents whom EBP is indicated, EBP is employed when performing the following high contact resident care activities.

i. Dressing.

ii. Bathing. Showering.

iii. Transferring during extended resident contact time such as bathroom, daily cares, therapy sessions.

iv. Providing hygiene.

v. Changing linens.

vi. Changing briefs or assisting with toileting.

vii. Device care or use central line urinary catheter feeding tube tracheostomy. Ventilator.

viii. Wound Care. Any skin opening requiring a dressing.

f. Staff education regarding enhanced barrier precautions will be processed through the Infection Prevention and Control Program.

1) Water Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 99 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 0880 On 2/10/25, at 0955 interview with Facilities Services Manager-L Surveyor asked Facilities Services Manager (FSM)-L if the facility had a more specific waterflow diagraph depicting the dead legs and other Level of Harm - Minimal harm or areas of concern for Legionella contamination. FSM-L asked the Surveyor what a dead leg was. Surveyor potential for actual harm explained to FSM-L these were the areas that a water pipe may branch off the water system will dead end and are capped off and need to be flushed. FSM-L informed Surveyor that FSM-L was not aware if the Residents Affected - Many facility had dead legs, and that FSM-L was not aware of them being flushed. Surveyor asked FSM-L did any legionella testing on the water system. FSM-L informed Surveyor that FSM-L did not do testing. Surveyor asked FSM-L if the facility had any information on tracking flushing, testing, and monitoring the water system. FSM-L informed Surveyor FSM-L would look for that information.

On 02/11/25, at 03:37 PM, Surveyor interviewed (FSM)-L. Surveyor asked FSM-L is there another water flow schematic that shows more detail on where the dead legs are located and locations of hopper rooms, toilets, sinks. FSM-L asked Surveyors for clarification if the Surveyors were talking about the pipes, that the Surveyors discussed with FSM-L that are capped and not hooked up (referring to the dead legs). FMS-L stated I believe those pipes (referring to the dead legs) are usually located in lower level. FSM-L informed Surveyor FSM-L does not have a map of all the dead legs in the facility. Surveyor asked FSM-L does the facility have dead legs. FSM-L informed Surveyor the FSM-L was not aware if the facility had dead legs. Surveyor asked if FSM-L was aware that the facility needs to flush the dead legs if they have them. FSM-L informed the Surveyor that FSM-L has never flushed a dead leg in the waterflow system. Surveyors asked FSM-L if the facility had any diagrams, schematics of the facility piping with the dead legs or a list of hoppers, sinks rooms not being used. FSM-L informed Surveyors we have no other diagrams, schematics, lists of rooms that are not in use, hoppers, sinks or specific lists of which ones I flush. FSM-L informed Surveyors

the rooms not being used are the last 5 rooms by the loading docks and those are flushed at least monthly. Surveyors asked FSM-L if the facility had documentation of locations of these areas that are flushed and the date they were flushed. FSM-L informed Surveyors no I keep the information in my head, and I flush those 5 rooms not used at least once a month. FSM-L informed Surveyors that weekly flushing was done of all unused toilets and hoppers. FSM-L showed Surveyors a monthly log that shows a weekly date range and documents, Flush all toilets and hoopers not being used, Marked done on time by FSM-L, has logs: no has docs: no. Surveyors asked FSM-L if FSM-L attended and discussed water management with Quality Assurance or Infection Control committees. FSM-L informed Surveyors we have not discussed water management with Quality Assurance or Infection Control committee. Surveyors asked FSM-L what other interventions the facility implemented to prevent legionella. FSM-L informed Surveyors that FSM-L will flush

the unused toilets and the hopper rooms weekly or pour bleach down the drain if it smells. FSM-L informed Surveyors that a water treatment company comes once a year to flush and treat the system and the company came in December 2024. Surveyors asked FSM-L if any documentation from the water company and documentation could be provided to Surveyors. Surveyors asked FSM-L what other types of interventions are used in the facility to prevent legionella. FSM-L informed Surveyors no other interventions FSM-L can think of.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 99 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 0880 Surveyors asked FSM-L what the facility protocol with rooms that become empty for the period between admissions and discharges and when a room becomes empty and how is that communicated to FSM-L. Level of Harm - Minimal harm or FSM-L informed Surveyors FSM-L will get an in-house roster which tells me which rooms are recently empty potential for actual harm and they are cleaned. FSM-L informed Surveyor and then the rooms are checked every day for housekeeping issues such as cleanliness of the toilet, sink, and bed. Surveyors asked FSM-L what the Residents Affected - Many protocol was to make sure those room's water areas do not sit too long after they are initially cleaned. FSM-L informed Surveyors we have people coming in and out so fast the rooms do not sit very long. Surveyors asked if FSM-L had a list or schedule to indicate how long a room may have sat empty after it was cleaned. FSM-L informed Surveyors there were no lists or schedules. FSM-L informed Surveyors the rooms are cleaned after a resident leaves, housekeeping checks them daily to make sure they are still clean before a new person comes in. Surveyors asked FSM-L what would happen if a room sat empty over a week. FSM-L informed Surveyors that does not happen. The rooms fill fast after discharges. Surveyors asked how you would determine that a room sat for a long period without some kind of tracking system. FSM-L informed Surveyors FSM-L can keep track from memory and rooms do not sit empty for that that long. Surveyors asked FSM-L what was reason the Activity room bathroom water is turned off by the toilet. FSM-L informed Surveyors the FSM-L is waiting for a part to repair the seal by the tank. Surveyors asked FSM-L how long

the toilet has been out of service. FSM-L informed Surveyors It has been about a week that toilet has been out of service.

Surveyors asked FSM-L if FSM-F attended the Quality Assurance Performance Improvement QAPI meetings. FSM-L informed Surveyors FSM-L attends all the QAPI meetings.

Surveyors asked FSM-L what the facility protocol for tracking temperature data and making sure temperatures of the water tanks are kept in correct temperature ranges that will discourage bacteria or Legionella growth. FSM-L informed Surveyors FSM-L doesn't recall the exact temperatures right now, but FSM-L takes temperatures once a week. FSM-L informed Surveyor FSM-L will pick 4 tanks for a temperature check each week. Surveyors asked FSM-L does the facility visualize and check temperatures entering the mixing valves before water goes to the facility. FSM-L informed Surveyors FSM-L will go into the mechanical rooms and check the temperature gauges on the tanks and if there is a problem FSM-L will call a plumber. Surveyors asked FSM-L for the documentation of all the different temperature checks FSM-L performs. FSM-L informed Surveyors that FSM-L does not document those temperature checks. Surveyors asked FSM-L how the facility would know which tanks and valves have been checked and when to check them again if there is no documentation. FSM-L informed Surveyors that FSM-L keeps that data in memory.

Surveyors asked if there had been Legionella in the building the past year. FSM-L informed Surveyors we have not had legionella in the building in the last year.

On 02/11/25, at 04:01 PM, FSM-L gave Surveyors the water management company's service report. Surveyors asked FSM-L if FSM-L could explain the meaning of the testing results by the water management company. Surveyors informed FSM-L the Surveyors were unfamiliar with these tests and their meanings. FSM-L said that FSM-L would make a call to the company to find out for the Surveyors what the tests meant.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 99 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 0880 On 02/13/25, at 01:40 PM, Surveyor interviewed Facilities Services Manager (FSM)-L. Surveyor asked FSM-L who wrote the water management plan for the facility. FSM-L informed Surveyor Nursing Home Level of Harm - Minimal harm or Administrator (NHA)-A and my former boss wrote the water management plan. Surveyor asked FSM-L if the potential for actual harm insurance company listed in the plan was part of writing the plan. FSM-L informed Surveyor that FSM-L did not know that information. Surveyor asked FSM-L does the facility do water testing for legionella or other Residents Affected - Many bacteria as part of the facility management plan. FSM-L informed Surveyor they have a water management company that comes once a year. FSM-L informed Surveyor FSM-L was not aware of what the company tested . FSM-L informed Surveyor we do not do water testing ourselves. Surveyor asked again if FSM-L could find out what the company testing results meant. FSM-L informed Surveyor FSM-L will make some calls and will get that information for Surveyors. Surveyor requested from FSM-L if a more facility specific waterflow diagram was available and if the facility has dead legs in the water system. Surveyor asked FSM-L for any logs related to temperature monitoring, flushing low use rooms and sinks, toilets in unused rooms, and any other water features. Surveyor asked FSM-L for documentation of inspections for biofilm in the system if it is warranted.

On 02/13/25, at 02:11 PM, Surveyor interviewed FSM-L and Nursing Home Administrator (NHA)-A. FSM-L informed Surveyor that the former director said it is not required to test for legionella or bacteria. NHA-A informed Surveyor that is maybe why testing is not in the water management program. Surveyor informed NHA-A and FSM-L the Surveyor asked if the facility did test as part of its plan. Surveyor informed NHA-A that

the Surveyor was told a water management company does testing and treatment of the system yearly. Surveyor informed NHA-A that a request was made for any logs related to temperature monitoring, flushing low use rooms and sinks, toilets in unused rooms, any water features if indicated. Surveyor asked NHA-A for documentation on inspections for biofilm in the system if warranted and the explanation for the testing by the water management company. Surveyor informed NHA-A that documentation was very basic with no parameters for the water temperature, no documentation of the temperatures taken, no responses to temperatures being out of range if any, no visual inspection observations, no system to determine how long rooms sit after they are cleaned, and no diagram showing dead legs or other potentially hazardous areas. NHA-A informed Surveyor NHA-A was not aware of what a dead leg was and where a dead leg may be located. NHA-A informed Surveyor the facility sent this water management program in with the last Plan of Correction, and it was deemed good at that time. Surveyor asked NHA-A if the water management plan interventions such as specific flushing of water feature, temperature monitoring and visual inspections of the system are not documented how does the facility know if they are in acceptable ranges to prevent bacterial growth. Surveyor informed NHA-A there is no comprehensive list of locations of all the water areas that need flushing or clear documentation of any interventions performed on these areas. Surveyor informed NHA-A that no temperatures have been documented for the mixing valves inspections and the water tanks that FSM-L selected for weekly temperature monitoring. FSM-L informed Surveyors that temperature monitoring and visual inspection intervention data are kept in FSM-L's memory. FSM-L informed Surveyors that the weekly flushing of areas of concern are documented in a non-specific weekly form. Surveyor asked FSM-L if there are data logs with these weekly forms. FSM-L informed Surveyor there are no data logs with these weekly forms. NHA-A informed Surveyor that NHA-A will further check into these concerns and ask for more information from the facility's corporate office. FSM-L informed Surveyor FSM-L will continue to follow up with

the water company and find out what the water is tested for.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 99 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 0880 On 02/13/25, at 02:59 PM, FSM-L informed Surveyor that FSM-L spoke with the Senior [NAME] President of Facility management. FSM-L informed Surveyor the Senior [NAME] Present believes the corporation was not Level of Harm - Minimal harm or required and had not done water testing. FSM-L told Surveyor that FSM-L believes there should be water potential for actual harm testing. Surveyor informed FSM-L that Surveyors concerns about lack of documentation that the water management plan is being implemented and it was not about water testing. Surveyor informed FSM-L that Residents Affected - Many water testing can be a part of the plan's evaluation of the plan's effectiveness. Surveyor's concerns are no specific documentation has been provided showing the plan has been implemented. Surveyor informed FSM-L that Surveyors are looking for temperature logs, inspection logs, flushing water systems documentation, and a comprehensive diagram with concern areas specific to this facility's waterflow system. Surveyor informed FSM-L the only real tracking data in the plan is the generic weekly log stating all toilets and hoppers have been flushed on time.

On 02/13/25, at 03:47 PM, NHA-A requested Surveyor to clarify the water management program issues. Surveyor informed the NHA-A that the Center for Disease Control (CDC) recommendations are Control measures: Flushing. Recommendations: Flush low-flow pipe runs and dead legs at least weekly. Flush infrequently used fixtures regularly. Disinfectant residual water areas. Visual inspection and keeping water temperatures. Recommendations: Store hot water above 140 F (60 C). Maintain circulating hot water above 120 F (49 C). Store and maintain circulating cold water below the growth range most favorable to Legionella (77-113 F, 25-45 C). Note that Legionella may grow at temperatures as low as 68 F (20 C).

Surveyor informed NHA-A that the facility has not provided documentation showing monitoring of the temperatures in the hot water tanks or mixing valves. Only a monthly generic flushing schedule with no indication of which areas are flushed weekly. All the data is kept in the Maintenance Manager's memory and not documented. Surveyor expressed concern to the NHA-A that no schedule or guideline has been shown to check when rooms sit for long periods of time. The facility only flushes the closed unit either weekly or monthly per FSM-L interview answers. Surveyor informed NHA-A that any documentation the facility could provide would be looked at.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 99 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 0880 02/17/25 10:10 AM, NHA-A and Regional Director Facility Services-M requested to speak with Surveyor. Surveyor expressed the following concerns to NHA-A and Regional Director Facility Services-M. Surveyor Level of Harm - Minimal harm or informed NHA-A that documentation shows a very generic weekly log for flushing of hoppers and toilets. potential for actual harm Surveyor informed NHA-A the generic log does not show tracking of which areas that flushing is completed. Surveyor informed NHA-A that during the interview with FSM-L the closed unit is done at least once a month Residents Affected - Many and then Surveyors were informed it was flushed weekly. Surveyor informed NHA-A there is no system documentation when rooms are vacated or how long the room sits open and if a room is flushed when a room sits over a week. Surveyor informed NHA-A there are no logs that temperatures have been kept above

the 140 degrees or within any parameters to control Legionella. Surveyor informed NHA-A there is no documentation of the water tank temperatures or mixing valve temperatures that FSM-L told Surveyors had been taken as part of the water management program. Surveyor informed NHA-A and Regional Director of Facility Services-M that FSM-L told Surveyor that the temperature for the tanks and mixing valves are completed, but the information is kept in FSM-L memory. FSM-L will call a plumber if temperatures are outside the proper temperature range with no documentation if a plumber was ever called or needed. Surveyor informed NHA-A that an activity bathroom has had the water turned off for about a week waiting for

a part with no plan to address the water sitting in those pipes for possibly 7 days or more. Surveyor informed NHA-A and Regional Director of Facility Services-M there is no documentation on if there are dead legs in

the facility and if they are flushed. Surveyor asked NHA-A if anyone knows if there are dead legs in the building. NHA-A informed Surveyor that the facility does not have that information currently. Surveyor informed NHA-A all information is in your Maintenance Managers memory, and if FSM-L left or was gone for some reason, how would another person follow up with the water management program. Surveyor informed NHA-A that Surveyors were unable to find the Water Management Program in or as part of the facility assessment. Surveyor informed them if they have any of these logs or documentation the Surveyor would look at them. NHA-A and Regional Director of Facilities-M told Surveyor they completely understood what Surveyors were looking for now and would look at how to implement tracking and look for the plumbing areas like the dead legs in question.

2) Infection Control

On 02/13/25, at 09:11 AM, Surveyor interviewed Assistant Director of Nurse (ADON)-G. Surveyor asked how long ADON-G was in the infection control position. ADON-G informed Surveyors since ADON-G started about 6 months ago. ADON-G informed Surveyors ADON-G did all the education required. ADON-G presented Surveyors with a 12/18/22 Infection Control Completion Certificate.

Surveyor asked ADON-G what outbreaks have occurred in the facility. ADON-G informed Surveyor 2 outbreaks occurred in the last year.

ADON-G informed Surveyor an influenza outbreak in December of 2024, with 7 people testing positive for influenza A. ADON-G informed Surveyor ADON-G let Waukesha public health know about the outbreak and

the patients were administered Tamiflu. ADON-G informed Surveyor the rest of the residents on that unit were administered prophylactic Tamiflu. Surveyor asked ADON-G what was done for isolation and infection spread prevention. ADON-G informed the Surveyor that the doors were closed, and the residents stayed in their rooms during their isolation period. Residents had to wear N 95 masks when they went off the unit

during their isolation. Housekeeping increased cleaning high touch areas including railings, tables, and door handles.

Surveyor asked ADON-G to tell Surveyors about the other facility outbreak.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 99 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 0880 ADON-D informed Surveyors a Covid outbreak happened beginning in August 2024. ADON-G informed Surveyor the Covid outbreak lasted from October 20th, 2024, to November 18th ,2024. ADON-G informed Level of Harm - Minimal harm or Surveyor the facility had an admission of a resident with Covid in October 2024. ADON informed Surveyors potential for actual harm the facility notified Waukesha public health immediately. Surveyors asked ADON-G if the residents and staff were tested for Covid. ADON-G informed Surveyor that Covid testing was done on all residents on the first Residents Affected - Many floor, and Covid testing was done on 7 staff who worked on the first-floor units during that period. ADON-G informed the Surveyor that the doors were closed, and the resident stayed in their rooms while isolated. ADON-G informed Surveyor residents had to wear N 95 masks when they went off the unit while in isolation. ADON-G informed Surveyors that housekeeping increased cleaning high touch areas such as railings, tables, and door handles.

Surveyor asked ADON-G when the facility considered Covid an outbreak. ADON-G informed Surveyor on August 23 once they had a positive resident and 3 days later 2 more residents tested positive for Covid. ADON-G informed Surveyor on the same day of the 3rd case public health was informed. Surveyor asked ADON-G for the documentation of the timeline of what the facility implemented and steps for prevention, when signs were placed, when isolation began and for whom and when each person began symptoms, when symptoms resolved, what analysis afterward was completed, quality improvement analysis of what could have been done better, analysis of what the facility could do to improve the process. Surveyors informed ADON-G the surveillance infection line lists that ADON-G provided to Surveyors didn't contain all the information required. ADON-G informed Surveyor ADON-G did not write down a timeline or summary which included the analysis of the outbreaks and what they could do to improve practice in the future. ADON-G informed Surveyors that ADON-G was recently made aware this process had to be done with each outbreak by their corporate infection control in January 2025. ADON-G informed Surveyors that ADON-G had already been working on writing the outbreak timelines out before the Survey started.

Surveyors asked ADON-G was the first Covid person/case ground 0 identified, and when illness started. ADON-G informed Surveyors a residents family member came down with Covid. Surveyor asked ADON-G how they determined that was the first case of Covid. ADON-G informed Surveyors the family notified the facility about the family member testing positive for Covid. The facility had no illness prior to the notification of Covid from the family member.

Surveyors asked ADON-G if the influenza outbreak was tracked from the start of the outbreak and documented on a timeline and evaluation of the outbreak. ADON-G informed Surveyor one staff member tested positive for Influenza A. ADON-G informed Surveyor after that Influenza positive staff member; the residents started having symptoms at the same time. The facility determined it was brought in from the community by that staff member. The facility tested all symptomatic people, and the symptomatic people tested positive for influenza A.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 99 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 0880 Surveyor asked ADON-A what was done instead of a timeline for these outbreaks on tracking when they started, what interventions were done and when the interventions were put in place, what analysis of what Level of Harm - Minimal harm or worked, what problems occurred and what could have been done to improve the process and the follow up. potential for actual harm ADON-G informed the Surveyor instead of doing a timeline or evaluations ADON-G informed Surveyor that ADON-G would swab the residents for the infections and then go by what Public Health told me to do. Residents Affected - Many ADON-G informed Surveyors I did not write down anything on a timeline or evaluate how to prevent the spread in the future. ADON-G informed Surveyors that ADON-G had just become aware of this process recently and this will be done differently in the future. ADON-G informed Surveyors ADON-G was only recently informed that documentation was required, but did have start and resolution of resident's symptoms

on the line list. Surveyor asked ADON-G is there anymore document [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 99 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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20483 potential for actual harm Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship Residents Affected - Few program for 1 (Resident R23) of 1 residents reviewed for antibiotic use.

* Resident R23 was treated with an antibiotic for a UTI (urinary tract infection) without meeting criteria.

Findings include:

The facility's policy titled, Infection Prevention and Control Program dated as last reviewed on 12/5/24 under

the Identification section documents: Staff will follow McGeers criteria for infection identification.

The CDC (Centers for Disease Control and Prevention) Core Elements of Antibiotic Stewardship for Nursing Homes Appendix A: Policy and Practice Actions to Improve Antibiotic Use under the section Infection specific interventions to improve antibiotic use documents Reduce antibiotic use in asymptomatic bacteriuria (ASB).

The prevalence of ASB, bacteriuria without localizing signs or symptoms of infections, ranges from 25% to 50% in non-catheterized nursing home residents and up to 100% among those with long-term urinary catheters. Antibiotic use for treatment of ASB in nursing home residents does not confer with any long-term benefits in preventing symptomatic urinary tract infections (UTI) or improving mortality, and may actually increase the incidence of adverse drug events and result in subsequent infections with antibiotic-resistant pathogens.

1.) Resident R23's diagnoses includes retention of urine, obstructive & reflux uropathy, and neuromuscular dysfunction of bladder. Resident R23 is receiving hospice services.

Resident R23's physician order dated 11/1/24 documents: Indwelling Foley Catheter 16 fr (french) with 10 cc (cubic centimeters) balloon for urinary retention.

Resident R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 documents that Resident R23 has an indwelling catheter.

Resident R23's urinary incontinence and indwelling catheter CAA (care area assessment) dated 11/11/24 documents under the analysis of findings section: neurogenic bladder obstructive urop (uropathy) Foley cath (catheter) retention,. Under the care plan considerations section it documents: Proceed to plan of care. Maintain Foley cath-cath places at risk for infection. Goal for no complications/infections r/t (related to) cath.

Resident R23's nurses note dated 12/5/24, at 12:22 p.m. by Licensed Practical Nurse (LPN)-HH documents: Resident had concerns for burning in bladder. Hospice nurse changed Foley out and collected a UA (urinalysis). Residents catheter was kinked in 2 places. Hospice nurse only wants resident [NAME] sic (wearing) house coats or robes, NO pants. Check that tubing is draining and not kinked. UA with c&s (culture and sensitivity) was ordered, collected, faxed, confirmed by lab and urine is in the fridge.

Resident R23's nurses note dated 12/6/24, at 13:09 (1:09 p.m.) written by LPN-VV documents: lab orders reviewed NNO (no new orders).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 99 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 0881 Resident R23's physician order dated 12/9/24 documents: Sulfamethoxazole-Trimethoprim Tablet 800-160 mg (milligram). Give 1 tablet by mouth every morning and at bedtime for UTI for 7 Days. Level of Harm - Minimal harm or potential for actual harm Surveyor reviewed Resident R23's December 2024 MAR (medication administration record) and noted Resident R23 received

this antibiotic starting on 12/9/24 with the HS (hour sleep) dose and twice daily on 12/10/24, 12/11/24, Residents Affected - Few 12/12/24, 12/13/24, 12/14/24, & 12/15/25 and the AM (morning) dose on 12/16/24.

Resident R23's nurses note dated 12/10/24 at 00:11 (12:11 a.m.) written by LPN-E documents: Late entry from PM (evening) shift: Resident alert and responsive, continues on ABT (antibiotic) for UTI, Foley patent, draining amber urine. No adverse reactions noted from ABT. No c/o (complaint of) pain or discomfort.

Resident R23's nurses note dated 12/11/24 at 03:35 (3:35 a.m.) written by LPN-E documents: Late entry from PM shift: Resident alert and responsive, monitoring for FU (follow up)/fall, no injuries noted. ROM/WNL (range of motion/within normal limits), neuro checks negative, continues on ABT for UTI, no adverse reactions noted from ABT, Foley patent, draining amber urine. No c/o pain or discomfort.

Resident R23's nurses note dated 12/15/24 at 23:32 (11:32 p.m.) written by LPN-E documents: Resident alert and responsive, monitoring for unwitnessed fall, area to back of head is healing, no blood or drainage noted. ROM/WNL. Oxygen on @ (at) 2 L (liters)/min. via nasal cannula. Continues on ABT for UTI, no adverse reactions noted from ABT. No c/o pain or discomfort.

Resident R23's nurses note dated 12/20/24 at 01:09 (1:09 a.m.) written by LPN-E documents: Resident alert and responsive. Continues on ABT for UTI, Foley draining amber urine, no adverse reactions noted from ABT, no c/o pain or discomfort. Surveyor noted Resident R23's antibiotic ended on 12/16/24.

On 2/13/25, at 1:44 p.m., Surveyor asked Assistant Director of Nursing/Infection Preventionist (ADON/IP)- G how Resident R23 met the McGeers criteria, which is the facility's definition of infection, for urinary tract infection in December. ADON/IP-G informed Surveyor she spoke with the NP (Nurse Practitioner) about that and the family requested test for an UTI, that's why the NP ordered it. ADON/IP-G informed Surveyor the family said

she was confused. Surveyor asked ADON/IP-G if Surveyor could see how she the McGeers form she filled out for Resident R23. ADON/IP-G looked in her computer and informed Surveyor she didn't fill one out for her. Surveyor asked ADON/IP-G to look into how Resident R23 met their criteria for treating Resident R23 with an antibiotic and get back to Surveyor.

On 2/17/25, at 9:07 a.m., Surveyor informed ADON/IP-G Surveyor has not been provided with any information on how Resident R23 met their definition of infection for treating a UTI in December. ADON/IP-G informed Surveyor the family spoke with the NP and they wanted the UA. Surveyor informed ADON/IP-G Surveyor understood how the UA was ordered but how did Resident R23 meet the McGeers criteria which is their standard of practice for treating an UTI. ADON/IP-G replied she did not.

Surveyor was not provided with any additional information as to why Resident R23 was treated with an antibiotic without meeting the facility's definition of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 99 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51016 minimal harm [NAME] Residents Affected - Some 5 of 5 reviewed for immunization

No documentation of risk benefit in the medical record for 5 of 5 residents reviewed for immunizations.

FACILITY

Infection Control

02/17/25 10:10 AM interview with NHA and [NAME] Regional Director New in position Surveyor Explained what we are missing. While it shows weekly flushing of hoppers and toilets. It does not indicate tracking of which ones are done. The closed unit is done once a month per interview. Temperatures need to be kept above 140 and there is no documentation this is done. Maintenance says they do temp tanks and valves, but

they keep it in their head and call a plumber if temps are outside the proper temp range. Interviews state they keep that in their head. There are no indication where and if there are dead legs and if they flushed and no one can tell me any information. There is no tracking of when rooms are vacated and then flushed if over a week. The interview we were told the closed unit was flushed monthly and according to the CDC it must be weekly. But there are no tracking for which rooms are done and when. Just a generic weekly flushing schedule with no logs no docs noted on the side. Any questions. They had none. Surveyor told them there are no indications of testing chlorine levels or any testing mentioned or visualization of or documentation or charting of temperatures to indicate they are being successful. Everything is just in your maintenance managers memory. Surveyor informed them if they have any of these logs or documentation the Surveyor would look at them. They told Surveyor they completely understood what we were looking for now and would look at how to implement tracking and look for the plumbing areas like dead legs in questions.

CDC 2025 Legionella control measures

Described below are control measures and recommendations for each water parameter.

Sediment and biofilm

Control measures: Flushing, cleaning, and maintenance

Recommendations: Flush after an intrusion event (e.g., water main break).

Clean and maintain water system components regularly as indicated by water quality measurements. Components include water heaters, mixing valves, aerators, showerheads, hoses, and filters.

Temperature

Control measures: Control limits

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 99 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 0883 Recommendations: Store hot water above 140 F (60 C). Maintain circulating hot water above 120 F (49 C).

Level of Harm - Potential for Store and maintain circulating cold water below the growth range most favorable to Legionella (77-113 F, minimal harm 25-45 C). Note that Legionella may grow at temperatures as low as 68 F (20 C).

Residents Affected - Some Water age

Control measures: Flushing

Recommendations: Flush low-flow pipe runs and dead legs at least weekly.

Flush infrequently used fixtures regularly.

Disinfectant residual

Control measures: Control limitsA

Recommendations:

Chlorine: Detectable residual as directed by WMP.

Monochloramine: Detectable residual as directed by WMP.

Resources

Form: Legionella environmental assessment

Toolkit: Developing a water management program to reduce Legionella growth and spread in buildings

Training: Preventing Legionnaires' disease: A training on Legionella water management programs

Guidelines

ASHRAE Guideline 12 [Free read-only preview]

Water Management:

Through interview (or record review as necessary), determine whether the facility has: Assessed (e.g., description of the building water systems using text and flow diagrams) where Legionella and other opportunistic waterborne

pathogens can grow and spread; Measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 99 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 0883 nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency or EPA). For example, control measures can include visible inspections, disinfectant, temperature control (that may Level of Harm - Potential for require mixing valves to prevent scalding); A way to monitor the measures they have in place (e.g., testing minimal harm protocols, acceptable ranges), and established ways to intervene when control

Residents Affected - Some limits are not met; and Had a resident with legionellosis since the last recertification survey. Interview the infection preventionist (IP) to determine whether the facility has had a case(s). Interview the IP (and perform

record review as necessary) to determine what actions the facility took in response to the identified case in

the facility. The State Survey Agency should work with local/state public health authorities, if possible, to determine if the water management program was inadequate to prevent the growth of Legionella or other opportunistic waterborne pathogens and whether the facility implemented adequate prevention and control measures once the issue was identified.

02/17/25 07:59 AM Spoke with [NAME] gave infection control policy reviewed facility program on 12-24-24. Gave Surveyor the outbreak list and a timeline . Surveyor asked IP when the timelines of the out break were written. [NAME] informed the Surveyor that the timeline of the outbreaks that [NAME] wrote out last night. Gave Surveyor Pneumococcal policy which is the CDC print out

02/13/25 03:01 PM Exit meeting NHA and DON Explained pressure injury the 8-28 to 9-28 no skin assessments for a patient described in an interview that likes to stay in bed and is dependent for bed mobility and the 48 baseline care plan. No care planned refusal for boots and turning as per interview with floor nurse. Shows her bed mobility as being dependent with no interventions foot and offloading on an at risk resident. Waiting for the last review of the infection control program.

Water management. No documentation except and generic flush monthly schedule. No temperatures documented at tanks of mixing valves, no documented visual inspections, no diagraphs or lists of where the closed rooms or unused rooms. No diagrams of knowledge of if and where a dead leg may be and statements they have never been flushed. No documentations of anything following the CDC or other standards for preventing legionella

All sign out says Flush toilet and hoppers not being used this is only done monthly not weekly and not which ones. Marked done on time is all that is there.

Global water report looks like PH abd Alkiline only

02/13/25 03:47 PM interview with NHA Informed NHA that with the 2 outbreaks what the facility did not document any time time on what was done. When it started, when the signs were placed, what prevention and control measure like signage warning unit closed, isolation, when sx resolved on resident or staff and analysis of what worked and assessment for improvement what to do different in the future. Surveyor informed the NHA Surveyors are still waiting for the emails of the public health reporting and review of the program and copies of the line lists with the outbreaks. Surveyor informed the NHA they are doing infection rates incorrectly IP is doing general infection rates instead of focused infection rates based on the specific infection problems by infection versus census. Surveyor informed NHA that Risk and benefits are not documented in the record for immunizations or education, that IP informed surveyor they were done with the consents and the consent was the proof or risk and benefit education and that these should be in the resident medical record Surveyor informed NHA that a CNA went into a EBP room without hand hygiene and came out without hand hygiene. Surveyor informed NHA That these were all concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 99 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 0883 NHA aske Surveyor to clarify the water management program problems. Surveyor informed the NHA that the recommendation in the regulations say Control measures: Flushing. Recommendations: Flush low-flow pipe Level of Harm - Potential for runs and dead legs at least weekly. minimal harm Flush infrequently used fixtures regularly. Disinfectant residual water areas. Visual inspection and keeping Residents Affected - Some water temperatures Recommendations: Store hot water above 140 F (60 C). Maintain circulating hot water above 120 F (49 C). Store and maintain circulating cold water below the growth range most favorable to Legionella (77-113 F, 25-45 C). Note that Legionella may grow at temperatures as low as 68 F (20 C). The problem is that the facility has no documentation of what the temperatures are in the hot water tanks of mixing valves. Only a monthly generic flushing schedule with no indication of which areas were done. All the data is kept in the Maintenance managers head. No schedule or guideline to check when rooms sit for long periods of time. The facility only flushes the closed unit by admission once a month.

02/13/25 02:59 PM [NAME] brought in number for Senior VP we have never done it as far as he know we done water testing. [NAME] told Surveyor I agree there should be water testing

02/13/25 02:05 PM gave me old plan still looking for water testing information.

02/13/25 02:11 PM meeting with [NAME] and NHA. former director not required to test for anything Not legionella or bacteria. NHA states that maybe why its not in there. I discussed the deadlegs and the flushing of the rooms. She was not aware of the deadlegs and what they were. She said they sent this in with the POC last time and it was good. I asked if these temps are not documented how do you know if they are not acceptable ranges. I do not see a list of where all the water areas that need flushing or specific documentation. No temperatures have been documented for the tanks . NHA will further check into it to find more information from corporate. Surveyor told NHA he would check with the team. [NAME] will continue to f/u with global and find out what they tested for.

02/13/25 01:59 PM interview with [NAME] IP about [NAME] IP informed Surveyor that WiR says she is completed because of the number of Pneumonia vaccine she already has she has had. IP brought up the WIR screen for [NAME] it does designate her as completed on the web site. Surveyor asked if the risk and benefits and education were in the chart at all. IP informed the surveyor that All risk and benefits are in her office in the form of the consents because that is were they go over the risk and benefits and education. Surveyor asked IP to explain the process of residents immunization on admission. IP informed the Surveyor when residents come into the facility we offer immunizations we ask for them what they had before to find out

the residents information and check in WIR so we have there record. IP informed Surveyor that the admissions nurse usually [NAME] or whoever is doing the admission offers the immunizations they qualify for. When they are admitted we look at what they had on admission and then we offer what they qualify for. Surveyor asked who places the information in the chart IP informed Surveyor [NAME] puts them in or whoever does the admission. ultimately I oversee it to make sure. I do check WIR. Surveyor asked if that includes risks and benefits or education. IP informed Surveyor no they do not place that information in the chart. That is done with the consents in my office.

who and when was your water tested ?

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 99 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 0883 02/13/25 01:40 PM interview with [NAME] Who did your water management plan [NAME] or my former boss. Not the insurance company listed. Do you water testing for legionella or other bacteria . Could you find out Level of Harm - Potential for what they are testing for. Can you find out when and who did the water testing. I make some call and will get minimal harm that for you. Can you find out what global is testing for. I will call them and find out.

Residents Affected - Some Staff covid offering Surveyor interviewed. [NAME] Do they offer you covid vaccines I got it when I started. Do

they offer every year. yes. How do they. They remind up. You mean a sign up . yes they put signs up.

02/13/25 09:11 AM interview [NAME] ADON IP RN. Surveyor asked how long ADON was in position. answer Since I started for about 6 months. I have done the education . 12-18-9-22 web based training certificate presented .

Surveyor asked IP what if someone is having symptoms what do you do take us the through the process. IP informed Surveyor we put them on precautions and test them we have the rapid panel when we send them out. we will put them on precautions until we get results or until their sx subside . if we test them and negative we talk to the NP and maybe 24 hours . Surveyor asked IP how long are tour precautions. IP informed Surveyor they are on precautions for 7-10 days. Covid is 10 days influenza is 7 days and asymptomatic.

Surveyor asked IP what outbreaks have you had: IP answered Surveyor outbreaks we had a influenza outbreak in December we had 7 tested positive. we let Waukesha public health know. we gave the patients Tamiflu. We gave all the rest of the residents prophylactic Tamiflu on that unit . Surveyor asked what did you do for isolation and infection spread. IP answered we closed the doors and they stayed in their room and wear 95 masks when they went off the unit. housekeeping increased cleaning high touch areas, railings tables.

Surveyor asked IP have you had staff test positive for Covid and Influenza what did you do . IP informed Surveyor we had staff 1 staff positive. The staff take 7 -10 days off if negative test they come back 8th day or 10 days. without testing if asymptomatic 10 days

Surveyor asked IP was that the only outbreak the facility had. IP informed Surveyor We had a Covid outbreak back in august that one lasted from October 20 to November 18th. IP informed Surveyor we had an admission with Covid in October. we notified Waukesha public health. Surveyor asked IP were residents tested and staff tested IP informed Surveyor all residents were tested we had 7 staff during that period. Surveyor asked IP when did you allow staff to come back to work Answer 7 days get tested if negative and symptom subsided and no fever they could come back.

and was that only one unit. IP informed Surveyor they were all on first floor both A&B units, not upstairs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 99 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 0883 Surveyor asked IP When did you consider covid an outbreak . IP informed Surveyor On August 23. once we had a positive the 3rd day 2 more popped up positive. on the same day I told public health . Surveyor asked Level of Harm - Potential for IP do you have the documentation of what you did like steps for prevention, signs placed, isolation,, when minimal harm each person began symptom, when sx resolved, what you did afterwards to anaylis what could be done better, what could improve the process., IP informed Surveyor I did not write down the process nor the Residents Affected - Some prevention analysis and what we could do in the future. I was not aware unit recently I had to. on August 27 I told the public health dept we were in an outbreak IP showed Surveyors the EMAIL here is the email.

Surveyor asked IP Do you find out who and when it started or the first case ground 0. Answer IP informed Surveyors Resident family member of [NAME] had covid. Surveyor asked IP how they determines that was

the first case. IP informed Surveyor the family notified the facility. The facility had no illness prior to the notification from the family .

Surveyor asked IP Did you track when the Influenza outbreak started and what did you did with a timeline and evaluation

IP informed Surveyor we had one staff member that was positive. the residents started having sx at the same time. we determined it was brought in from the community. We tested all symptomatic people and they test positive for influenza. A.

Surveyor asked IP If you did not do any time line for these outbreaks on when it started, what you did and when, what you did you do and the follow up. IP informed the Surveyor instead of doing a time time I would just swab the residents for the infection. I did not write down anything on a timeline or evaluate how to prevent the spread in the future. I have just became aware of this recently and we will do this different in the future. I recently found out I was suppose to do that documentation.

Surveyor asked IP Do have anything else anywhere documented on a timeline and your course of action. IP informed Surveyor I do not have anything else related to the outbreak times lines. I didn't know at the time I needed to do that time line. I generally swab the resident then go by what public health told me. I have the emails with the public health . I will be printing out the emails for you

Surveyor asked IP For the influenza outbreak in December. when did you determine there was an outbreak. IP informed Surveyor on [DATE REDACTED]. Surveyor asked how did you determine that. IP answered We had a staff member call in and a 4 residents at the same time with sx. They were all on the same unit same side with the same staff member who works with them. Surveyor asked How many do you need to call it an outbreak. IP answer its 3.

Surveyor asked when she was informed about needing to write up these outbreaks. IP answered in January I was asked to start writing this up recently. I started writing it in January just the staff members in January. Suveyors asked if this was another outbreak IP informed Surveyor this was not an outbreak or involved the residents. I was told I needed to do this to track infections when they started

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 99 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 0883 Surveyor asked IP infection rates do you monitor them. IP answer yes. we discuss it in morning meeting we address it in QAPI . IP informed Surveyor the patients that we had were new admissions besides the Covid Level of Harm - Potential for and respiratory outbreaks. Surveyors asked what do you do when you start to notice infections and what minimal harm would you do to prevent them from increasing. IP answered in a previous building I would try to figure out the reason why an infection started like poor Peri-cares, poor nutrition , are they bed bound, then address those Residents Affected - Some issues, I did this to try to try to keep the amount infections down . Surveyor asked if there is anything else you do IP answer I would track it to see if the infections were decreasing . Surveyor asked where do you track that IP answer PCC is where we track infections. Surveyor asked How do you know if you are successful in decreasing a specific infection. IP Answer if we have a lot infections in b wing we would see if it showing a decrease in the numbers.

Surveyors asked Do you do infection one rate or based on prevalent infections. Answer we do a total infection rate. when it comes to specifics it tells you how many uti s. are you looking at numbers or rates of specific infections. IP answer total numbers of infections in general Surveyors asked IP do you calculate a rate for numbers for specific infections and current census for accuracy on specific infections. IP informed Surveyor general total numbers. Surveyors asked You do not figure out percentages like resident census day times a 1000 for each individual infection. IP answer no I do not do that. I look at the total numbers. Surveyors informed IP you need to determine for each individual infection rate to determine the accurate percentage the infection is increasing of decreasing.

Surveyor asked IP where refusals of immunization were documents IP informed Surveyor We would chart

the refusals in PCC. Everyone is offered these immunization when they come into the building . Surveyor asked IP do you go over the risks and benefits we go over the consents with the resident. Surveyor asked IP Do you document the risks and benefits in the medical record under immunizations. IP informed Surveyor no just the consents here in the office. Surveyors informed IP Risk and benefits must be in medical record. IP informed Surveyors The forms are not in medical record but they have them in the form of the consents when the residents sign them.

Surveyor ask if they have issues getting PPE. IOP answered we had no problems. i am not responsible for ordering but if I see we are low I will have [NAME] order

Surveyors asked if they attend QAPI I attend all of the QAPI meetings

Surveyors asked what IC model IP informed Surveyor Macgeers is what we uses. I look at all of the antibiotics when they are prescribe. I notify the nurse practitioner if it doesn't follow macgeers. Surveyors asked Do you evaluate all antibiotics for outside sources. like the hospital . IP answered We will call the hospital for report both sending and receiving the resident to and from hospital

Surveyors ASKED Do you look at it all antibiotics used here IP answered correct does -end date -what is for. If it intentionally put for like endocarditis that is fine. we use macgeers as our standard of practice.

Surveyors asked who does fit n95 testing . IP answered corporate comes in yearly and I do new employees

Surveyors asked who covers when IP is not here or If you are on vacation IP infromed Surveyor maybe the DON yes, I haven't taken a vacation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of 99 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 0883 Surveyors asked How do you monitor staff illness. When they call in what do they have to say. IP answer

The staff call in to the scheduler and they have to tell them their Sx and then they tell me their symptoms . Level of Harm - Potential for Surveyors asked What if they didn't get sx from staff IP answered I will call the staff member myself. If the minimal harm scheduler is or on call nurse got the information.

Residents Affected - Some Surveyors asked What communicable disease do you report.

CDIFF Covid Influenza MDRO.

Surveyors asked When was last time the IP program was reviewed . IP answered we discuss it QAPI we discuss it on wednesday/ IP informed Surveyors We need to see the last time the program was reviewed, I am not sure when that was.

Surveyors asked IP Explain day to day how do you become aware of infections. IP informed Surveyors We have the 24 hour board and we have a sheet wear symptoms are filled out. Surveyors asked IP what is the nurses responsibility IP informed Surveyors to notify the NP and place them on the 24 hour board. when we make rounds they get placed on the purple sheets. I notified the NP she orders chest x ray and shows pneumonia . We know what is going on it is a small building the NP calls me or I call the NP. On weekends or evenings the nurse will notify the NP and will call the on call phone. I will see it all on Monday. Are the Surveyors asked are nurses aware of this procedure IP informed Surveyors The nurses can do it and they know how to do it. I generally do it most of the time because I am here regularly. The nurses are suppose to call the on call manager. Surveyors asked IP How do you know if they are meeting the Macgeers. IP informed Surveyors I determine that. Surveyors asked IP do you fill out the MCGeers form. IP informed Surveyors yes I do myself. Surveyors asked IP when do you do the infection monitoring and when do you log them in the IC module that day or asap. IP informed Surveyors as soon as I am made aware or Monday when I come in Surveyors asked do you bring the infection log to QAPI IP informed Surveyors yes on Weds

we have discussion on falls infections skin and at QAPI. Surveyors asked the IP what do the logs contain, do you the logs start stop resolve reason date. IP answered That information is brought to the QAPI. Surveyors asked if we could see the logs. IP said she would bring them to us. Surveyors asked how do you determine enhanced barrier precautions. IP informed Surveyors any break in the body like foley catheter jp drain wounds. Surveyors asked what are staff expected to wear. IP answered gown and gloves for high touch care like transfers and cares. Surveyors asked How do staff know this information . IP answered we have the sign outside the door in Kardex orders care plan. Surveyors asked where the precaution carts are located. IP informed Surveyors outside rooms or one close enough to grab it. Surveyor let her know about Pat [NAME] has had no PPE outside until today. Staff has been observed transferring with out PPE. Surveyor asked if in

an EBP room do staff have to wear gloves with food tray set up or any expectation for hand hygiene. IP informed Surveyors BEFORE THEY PUT GLOVES ON we HAND HYGIENE . If they just need to drop food or they need to use hand sanitizer or wash hands before they enter and before they get out of an EBP room. Surveyor asked IP When they remove their gloves are they suppose hand hygiene. IP informed Surveyor yes they are. Surveyor informed IP about concerns with the CNA for room [ROOM NUMBER] EBP not using hand hygiene when entering and leaving

Complete series:

PCV13 at any age &

PPSV23 at = or ) than 65 yr greater than 5 years given PCV20 or PCV21

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of 99 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 0883 Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to

Level of Harm - Potential for adults =[AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at minimal harm any age and PPSV23 at or after the age of [AGE] years old Residents Affected - Some immunizations Pneumonia Influenza Covid

[NAME] 71 PPSV 23 09/09/2020 not greater than 5 years since had it Refused booster 12/17/2022 had complete series

Refusal influenza

Refusal Reason

Resident Refused

Confirmed By

Confirmation Date

10/09/2024

Education Provided

No

[NAME] acetlina Pneumococcal conjugate PCV20, po10/29/24 10/20/24 10/29/24

[NAME] Pneumococcal conjugate PCV20, 10/29/2024 10/03/2024 10/29/2024

[NAME] Pneumococcal conjugate PCV20, p 10/29/2024 10/03/2024 10/29/2024

02/17/25 10:51 AM was [NAME] offered the pneumococcal She is up to date per CDC. recommendation

Adults [AGE] years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they've already received both of the following:

PCV13 (but not PCV15 or PCV20) at any age

PPSV23 at or after the age of [AGE] years

These adults can talk with a vaccine provider and decide, together, whether to get vaccinated (i.e., receive PCV20 or PCV21).

[NAME] Prevnar 13 01/31/2017 PCV20 or PCV21 09/30/2024 11/17/2022 booster had complete series

Pneumovax Dose 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of 99 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 0883 01/31/2017

Level of Harm - Potential for pneumococcal polysaccharide PPV23 minimal harm 10/18/2011 Residents Affected - Some PPSV 23

10/18/2011

Pneumovax Dose 1

01/01/2004

OK to give Pneumonia vaccination according to the WIR registry guidelines

No directions specified for order.

Other Active 11/6/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of 99 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 0883 02/11/25 03:37 PM Interview with [NAME] manager maintenance. Surveyor asked [NAME] Is there another water flow schematic that shows more detail on where your dead legs are located and locations of hopper Level of Harm - Potential for rooms, toilets, sinks. [NAME] informed Surveyors', you mean the pipes that are capped and not hooked up, I minimal harm believe those pipes are usually in lower level. [NAME] informed Surveyor I do not have a map of all the dead legs in the facility. Surveyor asked [NAME] do you flush the dead legs, [NAME] informed the Surveyor I have Residents Affected - Some never flushed those pipes. Surveyors asked [NAME] if the facility had any diagrams , schematics of piping's or a list of hoppers, sinks rooms not being used. [NAME] informed Surveyors we have no other diagrams or schematics or lists of rooms we do not use or hoppers or sink or lists of which ones I flush . [NAME] informed Surveyors the rooms not being use were the last 5 rooms rooms by the loading docks are flushed at least monthly. Surveyors asked [NAME] if the facility had documentation of were these areas you flush are and when they were done. [NAME] informed Surveyors no i keep it in my head, and I flush those 5 rooms not used once a month. Surveyors asked [NAME] if he attended and discussed water management with QA or infection control committees. [NAME] informed Surveyors we have not discussed management with QA or IF control; committee. Surveyors asked [NAME] what else does the facility do to prevent legionella. [NAME] informed Surveyors that I flush once a month or pour bleach down the drain if it smells . [NAME] informed Surveyors that Global water treatment comes once a year to flush and treat the system and they just came recently. Surveyors asked [NAME] can we see that from global water documentations and do you do anything else to prevent legionella? [NAME] informed Surveyors not that I can think of. Surveyors asked [NAME] what do you do when a room is empty for awhile and how to you become aware when a room is empty. [NAME] informed Surveyors I get an in house roster which tells me which ones are empty and I check every day for housekeeping issues the toilet sink bed Surveyors asked [NAME] How do you make sure sure those rooms water areas do not sit to long . [NAME] informed Surveyors We have people coming in and out so the rooms do not sit very long. Surveyors asked [NAME] what was behind the Activity room bathroom water turned off by the toilet. [NAME] informed Surveyors I am waiting for a part to repair the seal by the tank. Surveyors asked [NAME] how long has the toilet been out of service [NAME] informed Surveyors It has been a week for that toilet. Surveyors asked [NAME] if he attended QAPI [NAME] informed Surveyors I do attend QAPI meetings. Surveyors asked [NAME] What is the temperature of the water tanks to make sure bacteria doesn't grow. [NAME] informed Surveyors I don't have the exact temperature right now but once a week I pick 4 tanks for a temperature check. Surveyors asked [NAME] what about checking temperatures by

the mixing valves before water goes to the facility [NAME] informed Surveyors I go into the mechanical rooms and check the temperature gauges on the tanks and if there is a problem we call a plumber. Surveyors asked [NAME] where the documentation for the temperature checks are located. [NAME] informed Surveyors I do not document that. Surveyors asked if there had been Legionella in the building the past year. [NAME] told Surveyors We have not hand legionella in the last year. 02/11/25 04:01 PM [NAME] gave Surveyor the global service report.

02/11/25 10:21 AM Spoke with IP nurse [NAME] who brought in line lists etc. Surveyor asked if IP would be here all week and we needed to speak to IP about the line lists after reviewed. [NAME] informed Surveyor

she would be here all week

02/11/25 09:55 AM interview with CNA Shanquil [NAME] . Surveyor asked CNA when you see a sign like this enhanced barrier precautions how do you know what to do when entering the room. CNA informed Surveyor

it tells right here (CNA points to Enhanced Barrier Sign instructions) the steps on the front of this sign on what you are suppose to do.

02/11/25 09:43 AM observation checked outside air vent under large grate couldn't see any lint. Air was moving freely on observation by surveyor

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of 99 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 0883 02/11/25 09:15 AM observation Laundry [NAME] Ploor. manager in charge of laundry maintenance and housekeeping. Surveyor asked [NAME] to explain the process of washing the resident personal laundry. Level of Harm - Potential for [NAME] informed the Surveyor that Housekeeping staff goes up to grab laundry with these grey wheeled minimal harm carts the rooms we do in house have a white hamper inside the door. [NAME] informed Surveyor the hampers have bags in them and the bags are tied up with the clothing in the bag and places in bin. Surveyor Residents Affected - Some asked which elevators are used [NAME] informed Surveyor we use the regular elevators in the front the ones

in the back are closed off and do not function. Surveyor asked [NAME] to explain the [NAME] process. [NAME] said the clothing comes down and are placed into the washers, staff remove gloves and wash their hands and then place the clean cloths into the dryers in a separate room over here. [NAME] informed Surveyor they wash their hands at the sink before they take clean cloths to the dryer. [NAME] informed Surveyor we have a labeler and label all new clothing when they come in. Surveyor asked what happens with lost items. [NAME] informed Surveyor here are the lost and found bins they will look through them for lost items and return them to the residents. Surveyor checked the lint traps and asked [NAME] when lint traps are cleaned [NAME] informed the Surveyor they are cleaned daily. Surveyor asked for the cleaning log [NAME] told the Surveyor they have a log kept with t [TRUNCATED]

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