Lindengrove Waukesha

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 25, 2025

  Based on observations, interviews, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (R13, R2, R8, and R19) of 6 residents reviewed for falls. * R13 experienced 2 falls on 7/18/25 and was sent to the emergency room. R13 was diagnosed with blunt head trauma, forehead laceration requiring sutures, and traumatic intracranial hemorrhage (bleeding on the brain). When R13 returned to the facility, R13 fell an additional 8 times between 7/18/25 through 9/7/25. Two of these falls resulted in R13 hitting his head again and required steri-strips to close the wounds. The 10 falls that R13 experienced at the facility were not thoroughly investigated and did not determine a root cause for R13's falls. […]

• Immediate jeopardy, isolatedF686Jun 11, 2024

  Based on observation, interview, and record review the facility did not ensure 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 1 (R8) of 3 residents reviewed for pressure injuries. R8 admitted to the facility with pressure injuries (PIs) on her left heel and right lateral foot which later resolved. R8 was assessed as high risk for PIs. Despite being at high risk, R8's physician's order for an air mattress was not implemented, a care plan for actual skin impairment was not initiated timely, and her weekly skin assessments were not completed weekly as per facility policy. […]

• Actual harm, isolatedF686Mar 27, 2024

  Based on record review, staff interview, and review of facility policy, the facility failed to ensure that a resident who was admitted without a pressure injury was properly assessed and monitored to prevent the development of a pressure injury for one resident (Resident (R) 5) out of three residents reviewed for pressure injuries. This resulted in the development of a facility acquired, stage 3 pressure injury. Findings include: Review of the facility's policy titled, Pressure Injury-Prevention and Managing Skin Integrity dated 08/10/2023 indicated, 3. Skin Checks: a. Skin checks will be done upon admission, readmission or as clinically indicated. b. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2024

  Based on observation, interview and record review the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety in the kitchen and 1 of 2 serving areas with the potential to affect 44 residents. * Garbage cans in the kitchen were observed to be very soiled and a lid was not on a garbage can next to a food preparation area. * Multiple items in the kitchen were found to be undated and several were uncovered. * The handwashing sink in the kitchen was very dirty. * The serving area on the second floor was found to have a mop and bucket with dirty water next to a cart for food trays. * Several food storage bins were observed to have the scoop stored inside the bin in direct contact with the product. […]

• No harm, potential for more than minimal, widespreadF812Jan 4, 2022

  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. Observations were made of the main facility kitchen as well as a satellite kitchen which is used to prepare and serve meals to the residents. Observations were made of expired items, food stored on the floor of the freezer, garbage cans without closing lids and the ice maker which needed to be cleaned. This deficient practice has the potential to affect 4 of the 4 residents who eat and receive their meals from the main serving kitchen and satellite kitchen. […]