Lindengrove Menomonee Falls

In the surveyor’s words

From the most serious findings on record at Lindengrove Menomonee Falls, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Nov 11, 2025

  Based on the comprehensive assessment of a resident, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 2 (R2 and R4) residents reviewed for pressure injuries. R2 admitted to the facility without pressure injuries and was identified to be at risk for pressure injuries. Care plan interventions to prevent pressure injuries were not implemented. […]

• Immediate jeopardy, isolatedF686Mar 3, 2025

  Based on observation, record review, and interview, the facility did not ensure 2 (R147 & R350) of 3 residents reviewed with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure injuries from developing. * R147 developed skin concerns of MASD (moisture-associated skin damage) noted at the facility on 10/28/24. There were no care plan revisions implemented and no comprehensive assessments completed. On 11/04/24, while at the hospital, R147 was found to have an infected sacral wound requiring debridement. […]

• Immediate jeopardy, isolatedF686Jan 17, 2024

  Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries from developing for 5 (R137, R40, R41, R27, and R18) of 8 residents reviewed for pressure injuries. *R137 was admitted to the facility on [DATE] after sustaining a right femur fracture following a fall at home. R137 had a Braden score of 11 indicating high risk for development of pressure injuries. R137 developed a skin tear and a reddened area on 10/25/23 and 10/30/23 respectively. The facility did not have a Care Plan to address bed mobility, repositioning, or incontinence until 11/8/2023, when R137 developed an unstageable pressure injury to the coccyx. […]

• Actual harm, isolatedF689Nov 11, 2025

  Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent an accident from occurring for 3 of 3 Residents (R1, R3, and R4) reviewed for accidents. *R3 had 10 unwitnessed falls, 3 were not thoroughly investigated for a root cause. On 7/19/25, R3 had an unwitnessed fall in which R3 sustained a left hip fracture. *R1's fall on 10/16/25 was not thoroughly investigated for a root cause. R1's fall interventions of brushing teeth after lunch, toileting schedule, call light in reach, and transferring using a gait belt were observed not to be implemented. *R4's call light was observed to not be within reach and received straws which R4 should not have due to an aspiration risk during the survey process. […]

• Actual harm, isolatedF684Mar 3, 2025

  Based on interview and record review, the facility did not ensure 1 (R297) of 13 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. * R297 was admitted to the facility on [DATE] with an order to the left shin which continued until 8/1/24. There is only one skin assessment of this area dated 5/25/24. On 7/22/24 Advanced Practice Nurse Prescriber-FFF progress note documents two dressings on R297 left lower extremity. There are no skin assessments of R297's left lower extremity as to why dressings were applied. On 7/28/24, R297's left forearm was identified as being bruised and red with an indentation from R297's watch being too tight. […]