Lindengrove New Berlin

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

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

(NHA)-A had talked to Resident R2 about the incident for about 20 minutes, but NHA-A never asked the name of the aide who stated they would take a picture of Resident R2's bowel movement. On 9/4/25, at 10:45am, Surveyor interviewed complainant who stated that on 8/31/25, Resident R2 called and stated an aide had wanted to take a picture of Resident R2's bowel movement. The complainant then emailed NHA-A immediately to alert of the situation.

The aide was identified to Surveyor. The email that was sent to NHA-A was forwarded to Surveyor with the time stamp of Sent: Sunday, August 31, 2025 7:41pm.On 9/4/25, at 12:03pm, Surveyor interviewed Nurse Supervisor-O who stated when Resident R1 or their daughter have a concern NHA-A talks to staff about it.On 9/8/25, at 8:08am, Surveyor interviewed NHA-A and was told a self-report was filed with the state agency. It is being actively investigated, and the investigation is due tomorrow. A copy of the Division of Quality Assurance form F-62617 was provided.Surveyor noted that the email notification indicated being sent on 8/31/25, at 7:41pm. The self report form F-62617, documented the date that the incident was discovered as 9/2/25. Surveyor noted that NHA-A had previously being informed of the incident on August 31, 2025 via email, but the facility did not report the incident then to the state agency. On 9/8/25, at 9:34am, Surveyor followed up with NHA-A regarding the process when an allegation comes in over a weekend or Holiday.

NHA-A stated a normal allegation would be reported to the nurse who then notifies the nurse manager. The nurse manager then reports concerns to the NHA-A. Surveyor asked if an email was sent on 8/31/25, why

the delay in reporting until 9/2/25. NHA-A responded that they did not receive the email until Tuesday due to

the holiday and that is when they responded and filed the self report. Surveyor asked if anyone else scans emails for time sensitive emails and was told no one else does. If it had been a time sensitive issue NHA-A stated they should have called a manager on duty. Surveyor noted during interview with NHA-A it was shared that Resident R2 and the Complainant have a preference for direct communication with NHA-A. NHA-A informed Surveyor that an assistant NHA has been hired and that NHA-A tried to have this person be the contact, but that did not work out, so NHA-A has remained the primary contact for Resident R2. NHA-A even puts it

on the calendar to attend the quarterly care conferences to keep up communication with Resident R2. On 9/8/25, at 10:50am, Surveyor informed NHA-A of the concern that there needs to be a process in place for allegations that come in over the weekend or holiday to be addressed timely and reported within the designated time frames. pNo additional information was provided as to why Resident R2's allegation of mistreatment and neglect was delayed in being reported to the State Agency.

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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

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lindengrove New Berlin

13755 W Fieldpointe Dr New Berlin, WI 53151

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 Residents Affected - Few

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

weekly. Surveyor showed the 7/24/25 Skin Only Evaluation to Nurse Supervisor-O and asked why notification to the physician was not done. Nurse Supervisor-O wanted to look into this.On 9/4/25, at 2:25pm, Nurse Supervisor-O followed up with Surveyor and stated they did not know about the rash on 7/24/25 and does not know why the physician wasn't notified.On 9/8/25, at 8:34am, Surveyor interviewed DON-B regarding the Skin Only Assessment completed on 7/24/25 indicating Resident R2 had a rash and the physician was not updated. DON-B stated she would look into it.On 9/8/25, at 9:31am, DON-B followed up with Surveyor that they talked to the nurse who charted the rash on 7/24/25 and they stated it was mild redness that they cleaned and put barrier cream on. Surveyor asked what the expectation would be for contacting the physician with skin concerns. DON-B stated that for mild redness they would not expect the nurse to contact the physician. DON-B stated the nurse put in a late entry progress note about the redness.Surveyor noted Resident R2's late entry progress note dated 9/8/25, documents Resident had a mild rash in abdominal folds-she was cleaned and dried well with barrier cream applied. A rash is not the same as mild redness. Surveyor noted that a rash was indicated on the Skin Only Evaluation completed on 7/24/25 and again in the late entry progress note dated 9/8/25.On 9/8/25, at 10:58am, Surveyor relayed concern to DON-B that Resident R2's physician was not contacted regarding Resident R2's rash found on 7/24/25.No additional information was provided regarding why Resident R2's physician was not contacted for treatment of Resident R2's rash found

on 7/24/25.

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

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lindengrove New Berlin

13755 W Fieldpointe Dr New Berlin, WI 53151

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 Level of Harm - Actual harm Residents Affected - Few

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

limits). EMS (emergency medical services) transported resident to [Name] Hospital. POA (power of attorney), on call NP, and Unit Manager notified. Care plan updated for meals with nurses station per resident preference.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 7/7/25 prepared by LPN/UM-I The summary of alleged incident documents Resident experienced an unwitnessed fall in the dining room following dinner. She was discovered on the floor by housekeeping staff. On assessment, resident had a minor laceration to the right forehead and mild bruising with minimal bleeding noted at the corner of her right eye. Resident reported, I was trying to pick up my hearing aide and I was sliding, then I fell. She denied striking her head. Further assessment revealed no additional injuries to the head or body. Vital signs were obtained and neurological checks were initiated, all within normal limits. EMS was contacted and the resident was transferred to [Name] Hospital for further evaluation. The POA, on-call NP, and Unit Manager were notified. Pertinent diagnoses include: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominate side, muscle weakness (generalized); polyarthritis, unspecified; repeated falls; spondylosis without myelopathy, lumbar region; strain of unspecified muscle; fascia and tendon at shoulder and upper arm level, right arm; type 2 diabetes mellitus; unspecified fall; unsteadiness on feet; vitamin D deficiency. The IDT reviewed the incident and determined that the fall occurred when the resident attempted to reach down to retrieve her hearing aid, causing her to slip from her wheelchair. The care plan was updated with: meals near nurses' station per resident preference. Also included in the facility's fall investigation is an in[TRUNCATED]

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