Lindengrove Menomonee Falls
Lindengrove Menomonee Falls in MENOMONEE FALLS, WI — inspection on March 3, 2025.
Found 21 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
or physician order in place to keep Albuterol at the bedside.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
2/10/25-no gowns ordered
2/11/25-200 gowns delivered On 2/13/25, at 11:20 AM, FSM-L informed Surveyor that FSM-L completes a count of available linen biweekly and last completed 2/10/25. FSM-L provided documentation of the count and confirmed to Surveyor that there were no gowns available on 2/10/25.
On 2/13/25, at 3:04 PM, Surveyor shared the concern with Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A that the facility did not have gowns available per R196 preference for bedtime from 2/8/25-2/11/25 in the facility. No further information has been provided by the facility.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
02/13/25 03:04 PM
DON-B and NHA-A Shared concern that over the wkend until Tuesday, there were no gowns available on both upstairs and downstairs and per Resident preference wanted gowns to sleep in. No further information was provided by the facility at this time.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
the air mattress, heel boots, turning and repositioning and wheelchair cushion should have been
On 2/17/25 at 3:05 PM, Surveyor informed DON-B and Nursing Home Administrator (NHA)-A of the
the required 48 hours of admission.
Within the facility's baseline care plan assessment form, the skin integrity health condition was not addressed and R350's skin integrity was the reason R350 was admitted to the facility. R350's skin integrity baseline care plan did not include individualized interventions that were documented on the hospital discharge summary.
No additional information was provided.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
catheter removed, no difficulties noted, resident's output was 1000 ml (milliliter).
being monitored for Foley removed, PVR (post void residual) 396, some hematuria, encouraged to
R297's nurses note dated 6/12/24 at 0817 (8:17 a.m.) written by Licensed Practical Nurse (LPN)-WW documents: Continue to monitored for Foley catheter removal.
Resident alert/orient.
Skin warm and dry. No issues noted.
Resident voiding without difficulties.
Denies any pain or discomfort at this time.
Will continue to monitor this shift.
Surveyor reviewed R297's care plans and noted the following care plans: Potential for decreased activity involvement and socialization initiated 3/12/24 & revised 5/30/24.
Potential alteration in nutrition abnormal labs, weight variance, and fluctuating intake initiated & revised 6/3/24.
Documented Pressure Ulcer initiated 5/24/24 & revised 5/25/24.
Advanced Directives initiated & revised 7/2/24.
Resident has limited physical mobility initiated 3/7/24 & revised 3/18/24.
Resident has impaired cognitive function/dementia or impaired though process initiated 5/24/24 & revised 5/25/24.
Resident wishes to remain at SNF (skilled nursing facility) for long term care initiated 7/2/24.
Resident has Diabetes Mellitus initiated 5/24/24 & revised 5/25/24.
Resident is high risk for falls initiated 5/24/24 & revised 5/25/24.
Resident has constipation initiated 5/24/24 & revised 5/25/24.
Resident has an potential for alteration in hematological status initiated & revised 6/4/24.
Resident uses antidepressant initiated 5/24/24 & revised 6/4/24.
Resident has depression initiated & revised 7/2/24.
Resident has potential for pain initiated 5/24/24 & revised 6/4/24.
Resident has impairment to skin integrity initiated 5/24/24 & revised 5/25/24.
Resident has Indwelling Catheter initiated 5/24/24 & revised 5/25/24.
Surveyor noted the facility did not develop an urinary continence care plan after R297's indwelling catheter was discontinued.
On 2/18/25, at 7:44 a.m., Surveyor asked Director of Nursing (DON)-B about the facility's care plan process.
DON-B informed Surveyor nursing, MDS, therapy, social services, dietary or dietitian are involved in care plans.
Surveyor asked if a urinary care plan would be developed after a resident's Foley catheter was discontinued. DON-B replied yes.
Surveyor asked DON-B if she knew why the facility did not develop a urinary care plan after R297's Foley catheter was discontinued. DON-B replied I don't know.
Surveyor asked who should of developed the new care plan. DON-B replied nursing.
Surveyor asked if the floor nurse would develop this care plan. DON-B informed Surveyor the floor nurse wouldn't have done it and it would of been nursing management or MDS.
No additional information was provided as to why the facility did not initiate a urinary care plan after R297's foley catheter was discontinued.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
Nursing Student-CCC if she called APNP-FFF.
Nursing Student-CCC replied yes.
Nursing Student-CCC
Surveyor asked Nursing Student-CCC if the nurse was LPN-H.
Nursing Student-CCC replied yes and
Nursing Student-CCC informed Surveyor she was working under LPN-H and remembers bits and pieces.
Surveyor informed Nursing Student-CCC Surveyor noted she created an order for a UA.
Nursing Student-CCC informed Surveyor R297 wasn't himself, he wasn't urinating or anything.
Surveyor asked if she spoke to APNP-FFF or did she text her.
Nursing Student-CCC informed Surveyor she believes LPN-H called her.
Surveyor asked Nursing Student-CCC if she spoke to any RN about R297's change of condition.
Nursing Student-CCC informed Surveyor she's pretty sure LPN-H communicated with the DON and didn't think there was an RN in the building.
Surveyor asked Nursing Student-CCC if any of the CNAs reported anything to her about R297.
Nursing Student-CCC replied no not that I recall.
Surveyor asked Nursing Student-CCC how she was aware R297 was not urinating.
Nursing Student-CCC informed Surveyor she can't recall and doesn't know if LPN-H told her but she remembers something in that nature and thinks R297 told her he wasn't able to go. LPN-H informed Surveyor this is the first time she has sent a patient out.
On 2/17/25, at 1:50 p.m., Surveyor interviewed Director of Nursing (DON)-B and asked what the expectation is if a resident has a change of condition and the nurse on the floor is a LPN. DON-B explained they would make their observations and update the MD (medical doctor) to get further orders.
Surveyor asked if there would be a RN assessment. DON-B replied there is, they let management know and we will take a look at the resident as well.
Surveyor asked DON-B if she remembers R297. DON-B replied slightly. DON-B informed Surveyor what she remembers R297 was a pleasant man, not many complaints, he was diabetic and there wasn't a lot of issues that she was informed of. DON-B informed Surveyor she knows he scratched himself a lot and he had cream ordered for that.
Surveyor asked if there was anything ordered other than cream. DON-B replied no.
Surveyor asked DON-B if a dressing was applied, would there be an assessment. DON-B replied there should be.
Surveyor informed DON-B of APNP-FFF's note on 7/22/24 which documents two dressings. DON-B reviewed R297's record and then informed Surveyor there is no assessment.
Surveyor asked DON-B if she was involved with R297's transfer to the hospital on 8/13/24. DON-B replied no.
Surveyor asked DON-B if she was contacted regarding R297's change of condition on 8/13/24. DON-B informed Surveyor they would of contacted the on call and doesn't recall being called.
Surveyor asked who was the on call RN. DON-B informed Surveyor she doesn't know.
Surveyor asked DON-B to look up who was on call the evening of 8/13/24 and get back to Surveyor. DON-B did not provide Surveyor with the name of the on call RN.
No additional information was provided.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
jeopardy to resident health or which included support surface assessments and updates. safety - 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: 2.) R350 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Dementia, Pressure ulcer of right buttock, and Pressure ulcer of left heel.
R350's admission Minimum Data Set assessment was in the process of being completed.
R350's Brief Interview for Mental Status (BIMS) assessment dated [DATE], documents a score of 4, indicating that R350 is severely cognitively impaired.
R350's admission Section GG assessment dated [DATE], documents R350 requires substantial/maximum assist for bed mobility and R350 is dependent for transfers.
R350's Braden Scale Assessment used for predicting pressure ulcer risk dated 2/6/25, documents that R350 is at risk for pressure injuries. R350 has an activated Power of Attorney (POA).
R350's hospital Wound/Skin Nurse Specialist Consult note dated 2/3/25 documents, in part: [R350] has a full thickness, stage 3 pressure injury to right buttock that measures 8 x 8 x 0.1 centimeters (cm) and a stage 1 pressure injury to R350's left heel that measures 2.5 x 2.5 cm.
R350's Hospital Discharge (D/C) summary dated 2/6/25 documents, in part: . discharge diagnoses: Pressure ulcers .
You need to follow wound care instructions .
Wound Care treatment to [Right] buttock: 1.
Cleanse wound with Puracyn Plus, saturate gauze and soak 5 minutes. 2.
Pat dry with gauze. 3.
Apply 3M Cavilon barrier to peri-wound skin. 4.
Apply [NAME] Tul A over wound. 5.
Cover with Sacral Mepilex. [Registered nurse (RN)] to assess wound and change dressing three times a week. [NAME] dressings with date applied.
Wound Care treatment to heels: 1.
Cleanse wound with Puracyn Plus, saturate gauze
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
include events prior to the fall itself.
Root cause is Resident trying to self transfer with interventions to place a fall sign and offer toileting every 2-3 hours and prn.
There is not documentation of possible causative factors leading up to the fall.
There is not documentation to support the interventions implemented.
Plan of care revised. admission MDS [DATE] has bims 14/15. No fall history.
Had 1 fall after admission.
Freq incontient of B/B not toileting plan. [DATE] ED visit has laceration with stitches 1/23/2025 14:44 Nurse's Note Note Text: resident back from ER visit due to unwitnessed fall. alert and oriented making needs known. states some pain to site.
Dissolvable stitches in place to dissolve in 7 days. follow up with MD in regards. VSS resting in bed 02/13/25 08:07 AM DON this is the only information is the. I spoke to the resident.
Nurse and CNA. He was trying to get up to use the toilet.
Don't know when he was last toileted. No additional information at this time. 02/13/25 09:37 AM has white sign with black lettering on wall of TV. the sign states Sop. call don't fall. In room with wheelchair watching TV.
Has call light in reach.
Has another sign by the side if their bed.
Resident can read it and understands what it means. 1/20/25 Fall Risk Assessment completed is at risk 13 4.) R39 was admitted to the facility on [DATE] with diagnoses of Dementia, End Stage Renal Disease and Dependence on Renal Dialysis.
R39's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/25 indicates that R39 requires maximal assistance with transfers and mobility.
Surveyor reviewed R39's medical record, including physician's orders, fall risk evaluation forms and comprehensive care plans.
R39's care [TRUNCATED]
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
located. DON-B stated in the Medication Administration Record (MAR) or TAR.
Surveyor asked if R346
Consultant-N of the concern that 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 R346 received the necessary services for monitoring of the indwelling catheter.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
oxygen tubing.
Surveyor accompanied DON-B into R23's room and showed DON-B R23's oxygen tubing
On 2/13/25, at 7:33 a.m., CNA/Med Tech-KK informed Surveyor DON-B is going to change the oxygen
On 2/13/25, at 11:33 a.m., Surveyor observed R23 sitting in a wheelchair with her legs extended and appears to be sleeping. 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 R23's oxygen tubing was not changed weekly according to physician orders.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
standards of practice for 1 (R39) of 1 Residents reviewed for dialysis.
* R39 receives dialysis three times per week. R39's dialysis center communication records are not being consistently completed by Facility nurses.
Findings include:
- R39 was admitted to the facility on [DATE] with diagnoses of Protein Calorie Malnutrition, End
Stage Renal Disease and Dependence on Renal Dialysis.
Surveyor reviewed R39's medical record, including physician's orders and comprehensive care plans.
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. R39's comprehensive care plan documents the following interventions: .Send Dialysis binder with 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 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 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 R39 goes to dialysis that there should be a dialysis communication form completed. RN-GGG confirmed with Surveyor that 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 R39's dialysis communication forms from their admission date of 7/12/24 to 2/11/25.
Surveyor reviewed R39's dialysis communication forms provided by the facility.
Surveyor noted facility did not fully complete 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 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 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 R39.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
nurse in charge on each shift.
serve as a charge nurse on each tour of duty.
* The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule.
This deficient practice has the potential to affect all 49 residents residing in the facility.
Findings include: On 2/11/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting and 1/20/25-2/10/25.
Surveyor was provided with the nursing schedules and nurse staff postings and noted the facility's nursing schedules did not designate who the charge nurse was for each tour of duty.
On 2/17/25, at 10:15 AM, Surveyor conducted an interview with Scheduler-HHH.
Scheduler-HHH is responsible for coordinating the facility's nursing schedule and preparing the facility's nurse staff postings.
Surveyor asked Schedule-HHH if they were aware there was not a charge nurse designated on the facility's nursing schedules for Quarter 4 (July 1st -September 30th, 2024) from 1/20/25-2/10/25.
Scheduler-HHH told Surveyor that they were not aware that it is a requirement to designate a charge nurse for each shift on the daily nursing schedule.
On 2/17/25 at 2:40 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern related to the facility's schedules not designating who the facility charge nurse would be on the facility's nursing schedules for Quarter 4 (July 1st -September 30th, 2024) from 1/20/25-2/10/25 for each tour of duty.
The facility did not provide any additional information as to why it did not ensure that the facility designated a charge nurse for each tour of duty.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
nurses on a full time basis.
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.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
minimal harm staff 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.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
Depression, unspecified -Start Date 11/06/2024 0600
Oral Tablet 100 MG daily from 11/6/24 to 2/15/25.
Anti-Depressant Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity(skin), Excess Weight Gain.
Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift -Start Date 11/04/2024
R36's MAR (medication administration record) has documented a start date of 11/4/24 to begin monitoring R3's antidepressant medications. No antidepressant medication monitoring is documented for R36 on the MAR from the date of 11/04/24 until the date of 2/15/25.
On 02/17/25, at 08:08 AM, Surveyor interviewed Director of Nursing (DON)-B.
Surveyor asked DON-B if there was antidepressant side effect monitoring documentation for R36 during the period 11/04/24 through 2/15/25.
Surveyor informed DON-B Surveyor could not find antidepressant side effect monitoring in R36's MAR from the date of 11/04/24 until 2/15/25. DON-B informed Surveyor that DON-B did not have the information but would investigate the antidepressant side effect monitoring for R36 On 02/17/25, at 02:03 PM, Surveyor interviewed DON-B.
Surveyor asked DON-B if anymore documentation was available on antidepressant side effect monitoring on R36. DON-B informed Surveyor DON-B could not find side effect monitoring documentation for R36's antidepressant medication from the date of 11/04/24 until the date of 2/15/25.
On 02/17/25, at 04:32 PM, Surveyor interviewed DON-B and Nursing Home Administer. (NHA)-A.
Surveyor asked DON-B if the facility could provide more information on the antidepressant side effect monitoring expectation of staff and lack of antidepressant side effect monitoring documentation for R36. DON-B informed Surveyor the expectation was antidepressant side effect monitoring should have been completed.
Surveyor informed DON-B and NHA-A Surveyor has a concern because R36 did not have documentation for antidepressant side effect monitoring on R36's MAR from 11/04/25 until the date of 2/15/25. DOB-B informed Surveyor the facility had no documentation, and that the facility made sure the side effect documentation was addressed and started on 2/15/25 for R36.
No additional information was provided.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
pumpkin bar was on the menu. RD-DD then informed Surveyor that on 2/12/25, the Residents
can change the ticket. RD-DD stated the cookie was peanutbutter and luckily no one has a peanut
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 R196 and R197 have not been receiving preferences as documented on R196, and R197's meal tickets.
No further information was provided by the facility. 4.) R347 was admitted to the facility on [DATE] with diagnosis that include stroke, weakness and vascular dementia.
R347 admission Minimum Data Set assessment dated [DATE] documents R347 is severely cognitively impaired. 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 R347's meal tray ticket does not always match what is served on 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 R347 will have to go without it. POA-GG stated that fruits and vegetables are important to R347.
On 2/13/25 at 10:21 AM, Surveyor observed R347 in R347's room with POA-GG. R347 was eating breakfast.
Surveyor asked POA-GG if R347 received everything R347 wanted and preferred on R347's breakfast tray. POA-GG indicated that R347 did not receive a banana and wanted a banana.
Surveyor reviewed 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 R347's breakfast tray on 2/13/25.
On 2/13/25 at 10:25 AM, Surveyor informed Licensed Practical Nurse (LPN)-HH that R347 did not receive a banana on R347's breakfast tray and R347 still preferred to receive the banana. LPN-HH indicated that LPN-HH will get a banana for R347.
Surveyor observed LPN-HH enter R347's room to give R347 a medication. LPN-HH spoke to R347 and POA-GG about getting R347 a banana.
On 2/13/25 at 1:43 PM, Surveyor observed R347 and POA-GG in R347's room.
Surveyor asked if R347 received the banana that was requested earlier in the day. POA-GG stated that R347 did not receive a banana.
On 2/13/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B about R347 not getting R347's choice of banana on R347's breakfast meal tray and after requesting it again, as of 1:43 PM, R347 had still not received the requested banana.
No additional information was provided.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
that the facility will be getting all new kitchen staff. No other information has been provided at this
On 2/17/25, at 8:59 AM, Surveyor observed Resident room breakfast trays being distributed.
Surveyor
carried a tray from the cart down to room [ROOM NUMBER] with uncovered oatmeal and applesauce, placed the tray on the isolation cart, donned a gown and went into the room.
On 2/17/25, at 9:06 AM, Surveyor observed CNA-FF carry a room tray from the cart still parked at 102 to room [ROOM NUMBER] and the applesauce is not covered.
On 2/17/25, at 9:12 AM, Surveyor observed CNA-EE carry a tray from the cart still parked at 102 with uncovered applesauce to room [ROOM NUMBER].
This is approximately 3 rooms down and across the hallway.
On 2/17/25, at 9:13 AM, Surveyor observed CNA-EE carry a tray from the cart still parked at 102 with uncovered cereal and applesauce, put the tray on isolation cart, and donned gown and gloves outside of room [ROOM NUMBER] and took the tray to room [ROOM NUMBER].
No additional information was provided.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
R33.9
RETENTION OF URINE, UNSPECIFIED N/A, not an acceptable Primary Diagnosis 11/1/2024 Diagnosis C 11/1/2024 plindo view I50.22 CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE Cardiovascular and Coagulations 1/6/2025 Diagnosis D 2/4/2025 plindo view N13.9 OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED Medical Management 11/5/2024 Diagnosis E 11/11/2024 plindo
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
F 0880 view
NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED
Medical Management 11/5/2024 Diagnosis F 11/11/2024 plindo view Z96.0 PRESENCE OF UROGENITAL IMPLANTS N/A, not an acceptable Primary Diagnosis 11/5/2024 Diagnosis G 11/11/2024 plindo view E11.9 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS NTA (2 pts) Medical Management 11/1/2024 Diagnosis H 11/1/2024 plindo
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
F 0880 view
CHRONIC RESPIRATORY FAILURE WITH HYPOXIA &n
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
12/10/24, 12/11/24, 12/12/24, 12/13/24, 12/14/24, & 12/15/25 and the AM (morning) dose on
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.
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.
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.
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 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 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 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 R23 met their criteria for treating 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 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 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 R23 was treated with an antibiotic without meeting the facility's definition of infection.
525421 03/03/2025
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
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
potential for actual harm iii.
Entity shall flush dead legs, water heaters and plumbing fixtures with chlorine.
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.
525421
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525421 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lindengrove Menomonee Falls W180 N8071 Town Hall Rd Menomonee Falls, WI 53051
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.