Lindengrove Mukwonago

In the surveyor’s words

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

• Actual harm, isolatedF686Mar 16, 2021

  Based on record review and staff interview, the facility did not ensure that 1 (Resident 1) of 2 sampled residents received care consistent with professional standards to prevent pressure injuries from developing. Resident (R) 1 was admitted to the facility without a pressure injury. R1 was assessed to have been at risk for pressure injury development. Interventions on the care plan to float heels to reduce pressure were not included in the Certified Nursing Assistant (CNA) Kardex. According to staff interviewed, directions to elevate R1's legs and free float R1s heels were not initiated upon admission and were implemented later but could not recall when. On 9/11/21, R1 was observed to have a broken blister on the left heel. […]

• No harm, potential for more than minimal, widespreadF812Dec 10, 2025

  Based on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 kitchens. *Food Services Manager-U was observed in the main kitchen preparing and handling food without wearing a hair restraint to cover facial hair. *The blender blade was observed not to be thoroughly cleaned and sanitized in the main kitchen between preparation of two puree foods. *Food debris was observed over several days on the main kitchen floor and underneath kitchen equipment in the main kitchen. *A jug of salsa with an open date labeled 6/4/25 was observed with other ready-to-serve condiments in a refrigerator in the main kitchen and was not discarded timely manner. […]

• No harm, potential for more than minimal, widespreadF812Dec 2, 2024

  Based on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect 3 of 3 kitchens serving food and 39 of 39 residents residing in the facility. * Vents over the sink and near the dishwasher in the main preparation kitchen were contaminated with dark brown spots on the surface. * Food in the 2 refrigerators in the main preparation kitchen was stored without an open on date and liquid egg cartons were not sealed. * The Rehab/West Unit did not have an approved dish washing machine. […]

• No harm, potential for more than minimal, patternF628Dec 10, 2025

  Based on interview and record review the facility did not ensure 4 (R1, R2, R50, & R3) of 4 residents reviewed for hospitalizations were notified of the reason for transfer/discharge and bed hold policy in writing to the resident & their representative. The facility's notice of transfer and bed hold form does not include the Ombudsman's email address. *R1 was admitted to the hospital on [DATE]. R1 and R1's POA did not receive in writing the reason for transfer/discharge and bed hold policy. The Ombudsman was not notified of R1 discharge to the hospital on 9/4/25. *R2 was discharged to the hospital on [DATE] & 10/30/25. R2 and R2's representative did not receive in writing the reason for transfer/discharge and bed hold policy. *R50 was discharged to the hospital on [DATE]. […]

• No harm, potential for more than minimal, isolatedF554Dec 10, 2025

  Based on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 resident was clinically appropriate to self-administer medications.R1 was observed with a white pill on R1's breakfast tray and approximately four pills in a medication cup on R1's breakfast tray located on the over bed table next to R1. R1 does not have a self-administration assessment. Findings include:The facility's policy dated May 2018 and titled, Self-Administration of Medications documents under the Policy section: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility… […]