Lindengrove Menomonee Falls

F 0580 Level of Harm - Minimal harm or potential for actual harm

Nursing (DON-B) and Sister Facility Nursing Home Administrator (SFNHA)-C that Resident R3's emergency contact was not contacted when Resident R3 fell on 6/30/25 and 7/12/25.No further information was provided by the facility as to why Resident R3's emergency contact/representative was not contacted when Resident R3 fell on 6/30/25 and 7/12/25 which per the facility's policy and procedure, Resident R3's emergency contact/representative should have been contacted.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

On 11/4/25 at 3:00 PM, during the daily exit meeting, the facility was advised of concern Resident R2's grievance contained an allegation of neglect that should have been reported to the State agency.

No additional information was provided. 7.) On 11/3/25, at 3:07 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Nurse Clinical Consultant (NCC)-X Surveyor asked for the grievance dated 8/12/25 involving Resident R1.

On 11/4/25, at 11:00 a.m., Surveyor reviewed the grievance dated 8/12/25 investigated by Prior Life Coach (PLC)-J. Surveyor noted the individual affected documents [Resident R1's name]. Under describe concern using factual terms documents Writer was call to resident room (anonymous resident) because she was concerned resident from across hall (Resident R1) was giving kitchen staff money. Writer ensured resident (anonymous resident) it will be addressed.

On 11/4/25, at 12:30 p.m., Surveyor asked NHA-A if the grievance involving Resident R1 dated 8/12/25 was reported to the State agency for an allegation of misappropriation. NHA-A informed Surveyor as long as she has worked at the facility Resident R1 has made statements about having to pay. NHA-A informed Surveyor it was not reported. Surveyor informed NHA-A the grievance was made by another resident, and the allegation of misappropriation should have been reported to the State agency.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

passing. PLC-J informed Surveyor the kitchen staff know they can't accept funds from residents. Surveyor asked PLC-J if she spoke to other residents to see if they had any concerns regarding having to give money to staff for their meals. PLC-J informed Surveyor she doesn't believe there were other residents in

the area, and she just spoke with the two residents, anonymous resident & Resident R1.

The facility did not conduct a thorough investigation for an allegation of misappropriation as there is no evidence which dietary staff were interviewed and PLC-J only interviewed anonymous resident & Resident R1 and did not interview other residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (Resident R4) of 1 resident reviewed for ADL's (Activities of Daily Living).*Resident R4 was to have maintained short fingernails per documented skin intervention. Resident R4 fingernails were observed during the survey process to have extremely long fingernails on all fingers of both hands.Findings Include:The facility's undated policy titled STANDARD ADL (activities of daily living) PROTOCOL documents:- ADLS: Dressing, grooming, eating, toileting, bathing, personal hygiene (oral care, face, hands), mobility, transfers- Problem: Individual requires assistance with Activities of Daily Living (ADLs)- Goal: Individual will preform ADL's at highest functional level with or without staff assist.- CNA (Certified Nursing Assistant):o Trim finger and toenails on bath/shower day and as needed unless diabetico Offer handwashing/sanitizing before meals.Resident R4 was admitted on [DATE REDACTED] with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (complete and partial loss of movement on right side of the body after ischemic stroke - decreased blood flow to the brain causing lasting physical and mental deficits), Aphasia (inability to understand or speak), Dysphagia (difficulty swallowing), weakness, and need For Assistance with Personal Care.Resident R4's Quarterly Minimum Data Set (MDS) completed 9/12/25 documented Resident R4 has severe cognitive impairment with a Brief

Interview Mental Status (BIMS) score of 3. The MDS documents: Resident R4 has unclear speech and is sometimes understood; Resident R4 has impairment on one side upper and lower; Resident R4 eats independently, requires partial to moderate assistance for hygiene, showering, dressing, toileting, and bed mobility; Resident R4 requires set up to supervision assistance for all transfers.Resident R4's comprehensive care plan for Resident R4 documented: The resident has potential impairment to skin integrity r/t (related to) fragile skin, assisted to reposition, incontinence, immobility and history of skin altercation. Scar tissue present to right buttock from prior healed area. Date initiated 6/9/25, revised 8/19/25.o Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated 6/9/25. Resident R4's activities of daily living (ADL) self care performance deficit related to Activity intolerance, fatigue, impaired balance-stroke related to hemiplegia care plan initiated 6/9/25 and revised on 6/17/25 documents:o BATHING/SHOWERING: check nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. Initiated on 6/9/25.o Praise all efforts at self care. Resident refuses cares at times. Date initiated 6/9/25, revised on 10/14/25R4's Kardex as of 11/3/25, which instructs Certified Nursing Assistants (CNA) in the care for Resident R4, documented:Skin Integrity: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.On 11/4/25, at 7:35 AM, Surveyor observed Resident R4 sleeping in bed and observed Resident R4's nails to be extremely long and dirty with debris. On 11/4/25, at 3:03 PM, Surveyor shared concerns with Nursing Home Administrator (NHA) -A, Director of Nursing (DON) -B, and Sister Facility NHA-C.The facility did not provide any additional information at this time as to why ADLs were not provided to Resident R4 as Resident R4's fingernails are extremely long and dirty.On 11/4/25, at 3:40 PM, Surveyor observed Resident R4 in bed with extremely long and dirty fingernails. On 11/5/25, at 8:42 AM, Surveyor observed Resident R4 in bed with extremely long and dirty fingernails.No additional information was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm

and Sister Facility NHA (SFNHA)-C that neurological checks had not been started and completed for Resident R3's unwitnessed falls on 6/30/25 and 7/12/25.

No additional information has been provided by the facility as to why neurological checks were not started and completed for Resident R3's unwitnessed falls on 6/30/25 and 7/12/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

On 11/4/25, at 3:40 PM, Surveyor noted Resident R4 in bed and Resident R4's heels were not offloaded to prevent the development of pressure injuries.

On 11/5/25, at 8:21 AM, Surveyor reviewed Resident R4's progress notes and did not see any refusal documentation from 11/4/25 for refusing repositioning and pillows.

On 11/5/25, at 8:42 AM, Surveyor observed Resident R4 in bed and Resident R4's heels were not offloaded to prevent the development of pressure injuries.

No additional information was provided.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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

room. Resident R1 has her head down and appears to be sleeping. Surveyor observed Resident R1's call light continues not to be in reach and is hanging on the headboard of Resident R1's bed.

Level of Harm - Actual harm Residents Affected - Few

On 11/4/25, at 8:36 a.m., Surveyor observed Resident R1's continues to be sitting in a wheelchair in Resident R1's room.

Surveyor observed Resident R1's call light continues to be hanging on the headboard of Resident R1's bed and is not in reach.

On 11/4/25, at 8:48 a.m., Surveyor observed Licensed Practical Nurse (LPN)-N deliver Resident R1's breakfast tray to Resident R1 who is sitting in a wheelchair in Resident R1's room. Surveyor observed after LPN-N left Resident R1's room, the call light continues to be hanging on the headboard of Resident R1's bed and is not in reach.

On 11/4/25, at 9:26 a.m., Surveyor observed Resident R1 sitting in a wheelchair in Resident R1's roo

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to prevent recurrence. Surveyor noted neither Resident R1's oxygen therapy or SOB/Emphysema/COPD care plans were revised to include this intervention.On 11/3/25, at 9:18 a.m., Surveyor observed Resident R1 sitting in a wheelchair in Resident R1's room with oxygen via nasal cannula. Surveyor observed the oxygen concentrator is set at 3.5 liters. Surveyor noted Resident R1's physician orders are for 2 liters.On 11/3/25, at 10:00 a.m., Surveyor observed Certified Nursing Assistant (CNA)-I stating to Resident R1 I'm going to fill up tank and then will bring you out. I'll be back. CNA-I then left Resident R1's room with the small portable oxygen tank. On 11/3/25, at 10:07 a.m., Surveyor observed CNA-I enter Resident R1's room with the small oxygen tank and then Licensed Practical Nurse (LPN)-N entered Resident R1's room. Resident R1's nasal cannula oxygen tubing was connected to the small tank and Resident R1 was wheeled out of her room. Resident R1's small oxygen tank was set at 2 liters and observations of Resident R1 until 3:50 p.m. revealed Resident R1 continued to receive oxygen via the small tank.On 11/4/25, at 7:06 a.m., Surveyor observed Resident R1 sitting in wheelchair in Resident R1's room receiving oxygen via nasal cannula. Surveyor observed Resident R1's oxygen concentrator is set at 3.5 liters, and the oxygen tubing is not one continuous tubing but two oxygen tubing connected together. Surveyor observed the tubing is green in color and clear.On 11/4/25, at 7:36 a.m., Surveyor observed Resident R1 continues to be sitting in a wheelchair in Resident R1's room. Resident R1 is receiving oxygen via nasal cannula and the oxygen concentrator continues to be set at 3.5 liters. The oxygen tubing is not one continuous tubing but two oxygen tubes connected.On 11/4/25, at 8:04 a.m., Surveyor observed Resident R1 continues to be sitting in a wheelchair in Resident R1's room receiving oxygen via nasal cannula. Resident R1's oxygen concentrator is set at 3.5 liters and there continues to be two oxygen tubes connected.On 11/4/25, at 8:36 a.m., Surveyor observed Resident R1 appears to be sleeping in a wheelchair in Resident R1's room. Resident R1's oxygen concentrator is set at 3.5 liters and there continues to be two oxygen tubes connected.On 11/4/25, at 8:48 a.m., Surveyor observed Licensed Practical Nurse (LPN)-N deliver Resident R1's breakfast tray to Resident R1 who is sitting in a wheelchair in Resident R1's room. Resident R1's oxygen concentrator continues to be set at 3.5 liters and Resident R1's oxygen tubing continues to have two tubing connected. Surveyor observed LPN-N did not adjust Resident R1's oxygen concentrator to 2 liters.On 11/4/25, at 9:26 a.m., Surveyor observed Resident R1 eating breakfast in Resident R1's room. Surveyor observed the oxygen concentrator is still set at 3.5 liters and there continues to be two oxygen tubing connected.On 11/4/25, at 9:35 a.m., Surveyor asked LPN-N what Resident R1's oxygen is supposed to be set at.

LPN-N replied 2 to 3 liters. Surveyor informed LPN-N Resident R1's physician orders are for 2 liters. LPN-N then accompanied Surveyor to Resident R1's room where Surveyor showed LPN-N Resident R1's oxygen concentrator is set at 3.5 liters. LPN-N then lowered Resident R1's oxygen concentrator to 2 liters.On 11/4/25, at 1:00 p.m., Surveyor asked Registered Nurse/Nurse Supervisor (RN/NS)-O about Resident R1's oxygen being disconnected and Resident R1 was hypoxic on 10/16/25. RN/NS-O informed Surveyor she was informed after the fact Resident R1's oxygen was not connected. RN/NS-O informed Surveyor when she was in Resident R1's room she did not notice it. Surveyor asked RN/NS-O how she became aware. RN/NS-O informed Surveyor she doesn't remember who came and told her that the ambulance found the oxygen disconnected at the connectors. Surveyor asked RN/NS-O what was implemented so this would not happen again. RN/NS-O informed Surveyor instead of a connector they want one continuous tube from the nasal cannula to the concentrator.On 11/4/25, at 1:08 p.m., Surveyor asked RN/NS-O to accompany Surveyor to Resident R1's room. Upon arrival to Resident R1's room, Surveyor showed RN/NS-O Resident R1's oxygen tubing with two oxygen tubes connecting. Surveyor informed RN/NS-O the intervention of one continuous tube was not added to Resident R1's care plan.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility did not provide routine and emergency drugs and biologicals to its residents (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident R2) of 4 residents reviewed.Resident R2's Mirtazapine was not given as ordered.Findings include:Resident R2 admitted to the facility on [DATE REDACTED] with diagnoses that included right femur fracture, atrial fibrillation, chronic kidney disease stage 4, type 2 diabetes mellitus, hypothyroidism and depression. Resident R2's Brief Interview for Mental Status score was 15, indicating no cognitive impairment.The facility policy titled Medication administration - general guidelines dated May 2018 documents:Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and

a medication distribution system to ensure safe administration of medications without unnecessary interruptions.11) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit.Resident R2's Medication Administration Record (MAR) documented an order for Mirtazapine 15 mg (milligrams) give 1.5 tablet by mouth at bedtime for depression - start date 8/6/25.On 9/9, 9/10 and 9/13/25 the medication was documented as 9 (other/see progress notes). There was no documentation in the progress notes as to why the medication was not given.Surveyor review of the facility Omni inventory of available medications indicated Mirtazapine 15 mg tablet available in contingency.On 11/4/25 at 8:20 AM, Surveyor spoke with Pharmacy-S regarding Resident R2's Mirtazapine. Pharmacy-S reported they received the script on 8/6/25 and sent 45 tablets (a month supply) to get through 9/3/25. She reported they received another script on 9/15/25 and sent another 45 tablets, and 38 tablets were returned when the resident discharged . Pharmacy-S reported she was not sure what

the facility did from 9/4-9/15/25, as she is unable to view the contingency removal, but Pharmacy Manager-T would be available this afternoon.On 11/4/25 at 3:45 PM, Surveyor spoke with Pharmacy Manager-T. He confirmed a 30-day supply of Mirtazapine was sent for Resident R2 on 8/6/25 which was enough to get through 9/3/25 and another 30-day supply was sent on 9/15/25. Pharmacy Manager-T reported the medication does not require a prescription, the facility only needs to remove the reorder label and fax the pharmacy for refill. Pharmacy Manager-T reviewed the Omnicel contingency for any medications removed for Resident R2. Pharmacy Manager-T advised Surveyor no doses of Mirtazapine were removed for Resident R2 from 9/5/25 to 9/15/25. Resident R2's MAR indicated at least 3 doses of Mirtazapine were not given (9/9, 9/10 and 9/13/25).

Although the MAR had check marks indicating the medication was given for the other dates between 9/5 and 9/14/25, Pharmacy confirmed no Mirtazapine was sent to the facility and the medication was not removed from contingency. On 11/4/25 at 10:52 AM, Nursing Home Administrator (NHA)-A was advised of concern regarding Resident R2's Mirtazapine not given as ordered. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/11/2025

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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Based on interview and record review, the facility did not ensure 5 of 5 direct care staff chosen at random received Quality Assurance and Performance Improvement (QAPI) training with the potential to affect all 43 residents in the facility.Certified nursing assistant (CNA)-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not receive QAPI training as a new hire.Findings include:On 11/11/2025, Surveyor requested from nursing home administrator (NHA)-A the documentation of training for CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG. NHA-A stated the facility used Relias, an online computer-based training program, for staff education.Surveyor reviewed the provided training transcripts for CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG. CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not have documentation of receiving QAPI training.Surveyor reviewed the Facility Assessment, last review/ approval date of 3/27/2025, which documents, Staff Education, Training, and Competencies: Each job description identifies the required education and credentials for the job. Staff education and credentials are verified prior to hiring. Each staff member has knowledge competency in the following:- Resident Rights- Abuse, Neglect, MisappropriationFire Basics- HIPPA Compliance- Lockout-Tagout Basics- Infection Control- Corporate Compliance and Ethics- IT Policies- Personnel Handbook- Trauma Informed Care- Dementia Management and Behavioral Health .Competencies are verified upon orientation, at least annually and as needed. The facility provides education and training in various ways. The staff training and education program is designed to ensure knowledge competency for all staff. Education is provided through the on-line learning system Relias . The training program is reviewed and revised each time the Facility Assessment is reviewed and /or revised.Surveyor noted QAPI training was not included in the topics in the training plan.On 11/11/2025, at 1:07pm, Surveyor interviewed nursing home administrator (NHA)-A and asked how it is ensured that staff have completed all required trainings. NHA-A stated corporate employee-HH will email NHA-A staff that have education to be completed. Surveyor shared concern CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not have documentation of receiving QAPI training. NHA-A shared a phone number for corporate employee-HH as NHA-A does not have knowledge of the Relias education staff has to complete.On 11/11/2025, at 1:15pm, Surveyor interviewed corporate employee-HH via phone who stated was unable to talk at the time due to driving to an appointment. Corporate employee-HH requested an email be sent by Surveyor with specific questions and requests to corporate employee-HH and corporate employee-II.On 11/11/2025, at 1:25pm, Surveyor sent an email to corporate employee-HH and corporate employee-II requesting QAPI education completed by CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG.On 11/11/2025, at 1:16pm, Surveyor shared concern with nurse clinical consultant (NCC)-X CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not have QAPI training documented and waiting

on reply back from corporate employee-HH or corporate employee-II. NCC-X stated staff was working on locating requesting documents.On 11/11/2025, at 2:21pm, Surveyor received an email from corporate employee documenting, . Every year a team sits down to review the training plan for the following year. Last year it was identified that we have a gap in QAPI training for our staff. We proactively assigned this to our staff for the 2025 calendar year. I will say that [Facility name] incorporates the input of our front line staff and asks that they actively participate in QAPI related initiatives. The QAPI training module is assigned to all staff in quarter (Q)4 of 2025.On 11/11/2025, at 2:30pm, Surveyor shared concern with NHA-A and NCC-X CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not receive QAPI training upon hire.

NHA-A and NCC-X did not have further concerns or questions.

Event ID:

Facility ID:

If continuation sheet