Lindengrove New Berlin
Lindengrove New Berlin in NEW BERLIN, WI — inspection on September 8, 2025.
Found 3 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
emailed NHA-A immediately to alert of the situation.
The aide was identified to Surveyor.
The email
their daughter have a concern NHA-A talks to staff about it.On 9/8/25, at 8:08am, Surveyor
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 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 R2. NHA-A even puts it on the calendar to attend the quarterly care conferences to keep up communication with 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 R2's allegation of mistreatment and neglect was delayed in being reported to the State Agency.
525064 09/08/2025
Lindengrove New Berlin 13755 W Fieldpointe Dr New Berlin, WI 53151
regarding the Skin Only Assessment completed on 7/24/25 indicating R2 had a rash and the physician
redness that they cleaned and put barrier cream on.
Surveyor asked what the expectation would be
expect the nurse to contact the physician. DON-B stated the nurse put in a late entry progress note about the redness.Surveyor noted 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 R2's physician was not contacted regarding R2's rash found on 7/24/25.No additional information was provided regarding why R2's physician was not contacted for treatment of R2's rash found on 7/24/25.
525064 09/08/2025
Lindengrove New Berlin 13755 W Fieldpointe Dr New Berlin, WI 53151
assessed, no injury noted, VSS, no c/o pain/discomfort, patient transferred back into bed with hoyer
diagnoses include weakness, DM, unsteadiness on feet, repeated falls and history of CVA. IDT
assistance.
Care plan updated to have soft touch call light in place.
Also included in the facility's fall investigation is an incident report dated 6/26/25, SBAR (situation, background, appearance, review and notify) dated 6/26/25, pain tool dated 6/26/25, fall risk evaluation dated 6/26/25, neurological flow sheet starting on 6/26/25 at 0715 (7:15 a.m.), R3's progress notes dated 6/26/25 at 07:15 (7:15 a.m.), 07:49 (7:49 a.m.) & 7:26 p.m., and R3's at risk for falls care plan initiated & revised 6/12/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R3, what was R3 doing, how was R3 positioned in bed, when was R3 last toileted, and were prior interventions in place at the time of R3's fall and whether these interventions continue to be effective.R3's nurses note dated 7/7/25 at 18:30 (6:30 p.m.) created on 8/21/25 by Licensed Practical Nurse/Unit Manager (LPN/UM)-I documents Resident had an unwitnessed fall in the dining room after dinner, discovered by housekeeping.
She sustained a minor forehead laceration and bruising near the right eye but denied hitting her head. No other injuries noted; vitals and neuro checks were WNL (within normal 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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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.