Lindengrove New Berlin

In the surveyor’s words

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

• Immediate jeopardy, patternF686May 23, 2023

  Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice, to prevent the development and to promote healing of pressure injuries for 4 (R3, R20, R15, and R16) of 4 residents reviewed for pressure injuries. * R3 was admitted to the facility on [DATE] with a deep tissue injury (DTI) to the left heel, an open area to the left buttock, and an open area to the right buttock. R3 had a care plan and interventions put in place for the DTI on the left heel but no care plan was put in place for the pressure injury to R3's left and right buttock. […]

• Immediate jeopardy, isolatedF686Jul 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 4 (R94, R8, R77, and R1) of 7 sampled residents reviewed for pressure injuries out of a total survey sample of 18 residents. * R94 admitted to the facility with a stage 2 sacrum pressure injury (PI) and was at risk for development of PIs. The facility failed to complete comprehensive assessments, implement physician's orders, address incontinence as a contributing factor to development of new PIs, and did not implement proactive pressure relieving interventions. […]

• Immediate jeopardy, isolatedF689Jul 20, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R95) of 1 resident reviewed for feeding assistance and 5 (R50, R18, R77, R1, and R3) of 9 residents reviewed for falls. * R95 was assessed to be dependent on staff for eating, requiring a mechanical soft diet, needing assistance with feeding, and needing to take small bites while eating. Speech Therapist (ST)-K informed Surveyor that facility staff should be within 2 feet and at the same table while R95 is eating. On 6/13/26, R95 was in the dining room. Certified Nursing Assistant (CNA)-PP left the dining room to deliver room trays. R95's was served a tuna sandwich which was placed in front of R95 without staff supervision. […]

• Immediate jeopardy, isolatedF689May 23, 2023

  Based on interview and record review, the facility did not ensure that each resident received needed supervision to prevent accidents for 4 (R4, R6, R11, & R9) of 5 residents reviewed for accidents. On 4/12/23, Certified Nursing Assistant (CNA)-Q was attempting to transfer R4 from the bed into bath chair using a sit to stand lift. CNA-Q transferred R4 by herself, not with assistance of 2, and did not secure R4 in the sit to stand lift properly. The RST (Resident Summary Template) care card dated 2/10/23 was not accurate as the transfer status documented Assist of 2+ with a gait belt when R4's transfer status was a Hoyer lift with an assist of 2 staff. R4 fell from the sit to stand hitting his head. RN-K assessed R4 on the floor, R4 was then transferred into bed using a Hoyer lift. […]

• Actual harm, isolatedF689Sep 8, 2025

  Based on observation, interview, and record review, the facility did not ensure 2 (R1 & R3) of 3 residents received adequate supervision and assistance devices to prevent accidents.*R1 was admitted to the facility on [DATE] with a history of falls. R1 fell on 8/11/25 while attempting to self transfer. The facility did not thoroughly investigate this fall and was aware of R1's multiple attempts to self transfer but did not address R1's self transferring behaviors. On 8/19/25 R1 fell, was transferred to the hospital and diagnosed with a pelvic fracture. R1 returned to the facility on 8/28/25. On 8/31/25 R1 fell. The facility did not thoroughly investigate this fall.*R3's falls on 6/26/25, 7/7/25, 7/13/25, 7/29/25, 8/2/25, 8/20/25, & 8/26/25 were not thoroughly investigated. […]