Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lindengrove Menomonee Falls during CMS and state inspections, most recent first.
The facility failed to resolve and document repeated grievances raised in Resident Council meetings regarding staff call light response and housekeeping services. Over several months, residents reported that staff, particularly on night shift, used personal phones while working, did not answer call lights, and turned off call lights without returning, with no documented investigation outcomes or resolution communicated back. Residents also repeatedly complained that rooms, bathrooms, and dining areas were not being cleaned adequately, despite notes that maintenance and the Facility Service Manager were informed and TELS work orders were placed. Interviews with the DON and Life Enrichment Director confirmed that while concerns were shared with department heads, staff reeducation and grievance resolution were not consistently documented, leaving grievances unresolved and undocumented in accordance with facility policy.
The facility failed to maintain clean and sanitary resident rooms, hallways, and dining rooms, resulting in persistent dirt, trash, food debris, and soiled items on floors and tables across two units. Surveyors observed repeated accumulations of debris under dining tables, black scuff marks, and unremoved used cups, napkins, and an opened supplement drink, as well as multiple resident rooms and hallways with dirt and trash on the floors. An LPN and a CNA reported that only two housekeepers were employed and that the upstairs dining room was cleaned only if CNAs swept it. A housekeeper stated they often worked alone, covered all areas, and could only spot clean before moving between units. The Facility Service Manager confirmed there were only two housekeepers for all common areas and rooms, with no specific assignments, checklist, or log, and the Executive Director acknowledged housekeeping concerns and the absence of a housekeeping policy, while the Life Enrichment Director reported residents had complained about inadequate housekeeping during Resident Council meetings.
Surveyors found that approved menu portion sizes were not followed during lunch and dinner meal service, affecting 53 residents. At lunch, a dietary aide used smaller #12 and #16 scoops instead of the required #8 scoop for items such as mashed potatoes, carrots, mechanical and ground chicken, and chef’s choice vegetables. At dinner, another dietary aide used a 4 oz. ladle instead of the required 6 oz. ladle for tomato soup. The RD reported that portion sizes were documented on approved menu extensions and that kitchen staff were expected to use standard portioning equipment, while the Executive Director could not locate a policy on following approved menus. The Dietary Manager acknowledged that lunch portions were underserved, and the DON stated the expectation that meals be served according to approved menus. These failures placed residents at risk for weight loss, malnutrition, and dissatisfaction with their meals.
The facility failed to report an allegation of abuse to the State Agency within the required timeframe after a resident, who was cognitively intact and had a buttocks wound, reported that a CNA took a picture of the wound. The CNA told staff she had only shown the resident an online image of a similar wound and denied taking a photo. Social services staff and the IDT concluded the situation was not abuse and did not submit a report, and review of grievance logs and FRI records confirmed no report was made. The DON could not clearly state what must be reported within two hours, and leadership indicated that reporting decisions were based on the outcome of internal investigations rather than treating the resident’s allegation as a reportable abuse allegation.
The facility failed to thoroughly investigate an abuse allegation after a resident reported that a CNA took a picture of the resident’s buttocks wound. The resident, who was cognitively intact per MDS, alleged the photo was taken, while the CNA stated she had only shown an online image of a similar wound to encourage compliance with care. Social services staff stated that they interviewed the CNA and multiple staff, but there was no documentation of these interviews and no residents were interviewed. The administrator did not provide evidence of an investigation and refused to answer surveyor questions, leaving the abuse allegation unsubstantiated and undocumented in violation of the facility’s abuse investigation policy.
Two residents at risk for pressure injuries did not receive required preventive interventions, including accurate risk assessments, scheduled repositioning, offloading, and incontinence care. One developed a facility-acquired unstageable pressure injury that became infected, with care plan updates and treatments not consistently implemented. Another was repeatedly observed without heel offloading as required, and refusals of care were not documented. Facility policy and professional standards for pressure injury prevention and care were not followed.
Three residents experienced repeated falls and safety hazards due to the facility's failure to implement and monitor individualized fall prevention interventions, conduct thorough investigations, and ensure staff followed care plans. One resident had multiple unwitnessed falls, mostly while attempting to use the bathroom, without consistent documentation or root cause analysis. Another resident's fall was not fully investigated, and required interventions such as proper footwear, call light accessibility, and toileting assistance were not in place. A third resident was observed with the call light out of reach and given straws despite an aspiration risk.
Surveyors identified that multiple allegations of neglect and misappropriation, such as residents not being changed for extended periods, excessive call light response times, and possible financial exploitation, were not reported to the State Survey Agency as required. Facility staff and leadership did not follow internal policies for reporting, and interviews revealed confusion among staff about what incidents required escalation and external reporting.
Multiple allegations of neglect and misappropriation were not thoroughly investigated, including reports of residents not being changed for extended periods, long call light response times, and possible misappropriation of property. The facility did not obtain staff statements or interview other residents to determine if there was a pattern, and staff interviews revealed confusion about investigation procedures and incomplete documentation.
Five direct care staff members did not receive required QAPI training upon hire, as confirmed by a review of training records and interviews with facility and corporate staff. The facility's training plan did not include QAPI, and the process for tracking training completion was insufficient, potentially impacting all residents.
A resident experienced two unwitnessed falls and the facility did not notify the resident's emergency contact or representative as required by policy. The resident, who had multiple medical conditions and moderate cognitive impairment, stated that his wife should be informed of all events. The DON indicated notification was unnecessary, but there was no documentation that the resident declined such notification.
A resident with severe cognitive and physical impairments was not provided with necessary assistance for ADLs, specifically nail care, as required by their care plan and facility policy. The resident was repeatedly observed to have extremely long and dirty fingernails, and facility staff could not explain why the required grooming was not performed.
Three residents did not receive care according to professional standards and physician orders, including delayed and incomplete assessment after a fall with head injury for a resident on anticoagulants, failure to obtain a required stool sample for C. diff testing, and lack of neurological checks after unwitnessed falls. Staff were unable to provide timely information to emergency responders, and required documentation and follow-up were missing.
A resident with severe cognitive impairment and chronic respiratory conditions did not receive oxygen therapy as ordered, with repeated observations showing the oxygen concentrator set above the prescribed rate and the use of two connected oxygen tubes instead of a single continuous tube. Staff failed to follow physician orders and did not update care plans to reflect necessary interventions after a hypoxic event caused by disconnected tubing.
A resident with depression and other medical conditions did not receive prescribed doses of Mirtazapine on several occasions due to lapses in medication management, including failure to obtain medication from contingency supply or contact the pharmacy, and lack of documentation explaining the missed doses.
A resident with cognitive impairment and significant physical disabilities was found to have a closed right ankle fracture of undetermined age after complaining of pain and being sent to the hospital. Although the LPN promptly informed the DON and Administrator, the facility delayed reporting the injury of unknown origin to the State Survey Agency by five days due to uncertainty from the Interim Administrator about whether the event was reportable.
A resident with significant physical and cognitive impairments sustained a closed ankle fracture after complaining of pain and being sent to the hospital. The facility did not interview all staff involved in the resident's care prior to the injury, including those with direct knowledge of the incident. The investigation concluded the likely cause was improper transfer by staff, but this could not be verified due to incomplete staff interviews.
A resident was not permitted to participate in the creation and execution of their person-centered care plan, as required, resulting in a deficiency related to resident involvement in care planning.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with severe cognitive impairment and partial ADL assistance experienced repeated loss of dentures, but the care plan was not updated to include interventions for safe storage. Staff interviews revealed inconsistent denture management practices, and the care plan continued to lack specific instructions despite facility policy requiring revisions based on resident needs.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in the resident's functional abilities was clinically unavoidable, as required, and surveyors found no evidence in the records to justify the loss.
A resident with significant functional impairments and severe cognitive deficits did not receive timely PT and OT services as ordered by their physician. Although new therapy orders were written, there was a delay of several weeks before therapy was initiated due to a lack of communication and absence of a clear process for notifying the therapy department of new orders from external physicians. The deficiency was compounded by the absence of a facility policy for following physician orders related to rehabilitation services.
The facility failed to provide necessary treatment and services for two residents with pressure injuries, leading to immediate jeopardy for one resident. A resident developed a stage 4 pressure injury requiring debridement, and the facility did not revise the care plan or conduct comprehensive assessments. Another resident was admitted with pressure injuries, but preventative interventions were not observed. The facility's failure to follow its policy on pressure injury prevention and management resulted in significant deficiencies.
A resident with multiple diagnoses, including Alzheimer's, experienced inadequate care at an LTC facility. Despite orders for wound care and changes in skin integrity, comprehensive assessments were lacking. On one occasion, the resident's condition worsened with a high fever and altered mental status, yet timely interventions were not made, leading to hospitalization for sepsis and UTI. The facility's policy on change of condition was not followed, contributing to the resident's decline and eventual death.
A long-term care facility failed to provide adequate supervision and fall prevention for residents, leading to multiple falls. Residents with severe cognitive impairments and high fall risks experienced falls that were not thoroughly investigated, and fall interventions were inconsistently implemented. Observations revealed that call lights were often out of reach, and staff did not consistently follow care plan interventions, such as using gait belts during transfers.
The facility did not designate a charge nurse for each shift, as required. Upon review of nursing schedules for a specified period, it was found that the schedules lacked this designation. The scheduler responsible was unaware of the requirement, and the Nursing Home Administrator was informed of the issue without providing further explanation.
The facility failed to maintain sanitary conditions in food preparation and delivery, with issues including improper use of hair restraints by dietary staff, incomplete dish machine temperature logs, and uncovered meal items during tray delivery to resident rooms. These deficiencies were observed in both the kitchen and during meal service on Unit A.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours each day, as required. Review of staffing schedules and staff postings showed multiple dates where no RN was present for the required duration. The scheduler confirmed ongoing challenges in finding enough RNs, and while the DON sometimes covered shifts, this was not consistently documented. This deficiency had the potential to affect all residents in the facility.
The facility lacked a comprehensive infection prevention and control program, failing to maintain detailed water management records, perform and document required flushing and temperature checks, and analyze infection outbreaks with proper tracking and evaluation. Staff also did not consistently follow hand hygiene protocols for residents on enhanced barrier precautions, putting all residents at risk.
A resident with multiple medical conditions was unable to obtain a hospital gown for several nights due to a facility-wide linen shortage, despite expressing a preference for wearing a gown to bed. Staff and surveyor observations confirmed the absence of gowns on all units, and interviews indicated that such shortages occurred periodically. The facility's linen management process failed to ensure consistent gown availability, resulting in the resident having to sleep in day clothing.
A facility failed to develop a comprehensive care plan for a resident after their Foley catheter was removed. Despite the resident's complex medical history, including severe cognitive impairment and urinary retention, no urinary care plan was created post-catheter removal. The Director of Nursing acknowledged the oversight, noting that nursing management or MDS staff should have developed the plan, but it was not done, leading to a deficiency finding.
A resident with asthma and other medical conditions was found to have a PRN Albuterol inhaler stored at bedside without the required interdisciplinary assessment or physician order for self-administration, contrary to facility policy. The absence of documentation and authorization was confirmed through observation, interview, and record review, with facility leadership acknowledging the deficiency.
A nurse practitioner conducted a psychiatric interview with a resident in the dining room while other residents and a family member were present, discussing confidential medical and personal information in a non-private setting. The resident, who had severely impaired decision-making skills, had their lunch interrupted and required their meal to be reheated. Facility policies require privacy for such discussions, but the interview was not moved to a private area.
Two residents were admitted without having their baseline care plans developed, completed, or reviewed within 48 hours as required. One resident, cognitively intact and admitted with multiple medical issues, did not have a baseline care plan initiated or reviewed promptly. Another resident, admitted for wound care with severe cognitive impairment and an activated POA, had a baseline care plan that was incomplete, missing individualized interventions from the hospital discharge summary, and not reviewed with the POA within the required timeframe. Staff interviews confirmed lapses in following the facility's care planning process.
Two residents with indwelling catheters did not have their urinary output monitored and documented as ordered by physicians and required by care plans. Despite staff and leadership confirming that catheter output should be recorded every shift in the TAR or MAR, documentation was missing for extended periods for both residents. Staff could not explain the lack of documentation, and the DON was unaware of the issue until notified by surveyors.
A resident with chronic respiratory conditions was observed receiving oxygen therapy through tubing that had not been changed weekly as ordered by the physician. Despite facility policy and staff acknowledgment that tubing should be replaced every seven days, the tubing in use remained unchanged for an extended period, and no reason was provided for this lapse.
A resident with End Stage Renal Disease who required regular hemodialysis did not have dialysis communication records consistently completed by facility nurses, despite care plan instructions to do so. Multiple instances of incomplete or missing documentation were identified, and staff confirmed that forms should have been completed each dialysis day, but no explanation was provided for the lapses.
A resident with a history of atrial fibrillation and other conditions was prescribed Warfarin, but the facility failed to document required monitoring for adverse reactions as outlined in the care plan. Despite orders to monitor for side effects every shift, there was no evidence in the MARs or TARs that this monitoring occurred, a fact confirmed by the DON during interviews.
Three residents did not receive food items according to their documented meal preferences and meal tickets, including repeated serving of disliked foods, missing items such as fruit, and unannounced menu substitutions. Despite residents and their representatives communicating preferences and making requests, dietary staff failed to provide the correct items, and substitutions were made without informing residents.
A resident with a Foley catheter and complex urinary diagnoses was treated with antibiotics for a UTI without meeting the facility's infection criteria, as required by their antibiotic stewardship policy. Despite the absence of documented symptoms meeting McGeer's criteria, antibiotics were prescribed following a family request, and the necessary infection documentation was not completed.
The facility did not accurately post the daily nurse staffing information, failing to include the correct number of CNAs, Medication Technicians, LPNs, and RNs on each shift. This deficiency was identified through a review of schedules and staff postings, with facility staff unaware of the inaccuracies and unable to provide an explanation for the failure.
A resident with benign prostatic hyperplasia (BPH) was not provided with the ordered post void residual (PVR) assessments every shift due to a transcription error in the Treatment Administration Record (TAR). The resident occasionally complained of urinary frequency, but the nursing staff did not perform the PVRs as the order was not recorded in the TAR, leading to a lapse in care.
A resident experienced severe pain for 3.5 hours due to a delay in obtaining Oxycodone after lumbar surgery. The LPN did not notify the NP or DON about the delay, and the pharmacy required additional information to release the medication. The facility failed to follow its pain management policy, resulting in the resident's distress.
Failure to Resolve and Document Repeated Resident Grievances on Call Lights and Housekeeping
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely resolution and adequate documentation of grievances raised through Resident Council meetings, particularly regarding staff call light response and housekeeping services. Review of the facility’s grievance policy showed that individuals were to be informed of the grievance process and that a manager would investigate and respond within five working days, fostering prompt resolution and continuous process improvement. However, Resident Council minutes from multiple months documented recurring complaints without evidence that these grievances were resolved or that rationales were provided when they were not resolved. Resident Council minutes from December through March repeatedly documented residents’ concerns about staff attentiveness, including staff using personal phones while working, not answering call lights, and turning off call lights without returning to provide care. These concerns were noted across all shifts, with particular emphasis on third shift staff being on their phones, not answering call lights, and not doing rounds. The minutes showed that residents were repeatedly told to provide specific dates, times, and staff names before the facility would investigate, and that nursing management was made aware, but there was no documented follow-up, investigation outcomes, or resolution communicated back to the Resident Council. The repeated appearance of the same concerns in Old and New Business sections over several months showed that the issues persisted without documented closure. The minutes also documented ongoing grievances about housekeeping services, including resident rooms and bathrooms not being cleaned daily, toilets not being cleaned, trash not being removed, and the second-floor dining room tables and floors not being cleaned after meals. While the minutes noted that TELS work orders were placed, that maintenance and the Facility Service Manager (FSM) were made aware, and that staff would be responsible for cleaning dining room tables, there was no documentation that these actions resulted in sustained improvement. Residents continued to report unclean bathrooms and dining areas over several months. Interviews with the DON and Life Enrichment Director confirmed that while concerns were discussed with department heads, staff reeducation was not always documented, and there was no clear documentation of completed investigations or resolutions to close the loop on repeated grievances.
Failure to Maintain Clean and Sanitary Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, specifically by not ensuring that housekeeping services were performed adequately in resident rooms, hallways, and dining rooms on multiple units over three survey days. Surveyors observed the second-floor D unit dining room with papers and straws on tables, and food debris, trash, and dirt scattered across the floor and under tables. On subsequent observations, the same dining room had large black scuff marks, straw wrappers, large accumulations of food and dirt under numerous tables, used plastic cups and napkins left on tables and floors, and an opened supplement drink left on a table. Multiple resident rooms on D unit (including rooms 222, 223, 224, 226, 231, 232, 234, 237, and 243) were observed with dirt, debris, and trash on the floors, and soiled napkins were seen on the hallway floor with dirt throughout the hallway. Similar conditions were observed on the first-floor B unit, where the dining room floor had extensive food and dirt debris throughout the room and under tables on multiple days, and resident rooms on B unit had food and trash on the floors, with the hallway floor also showing significant dirt and debris. Staff interviews confirmed that housekeeping services were not being completed as they should. An LPN and a CNA reported that there were only two housekeepers for the facility and that the upstairs dining room would only be cleaned if CNAs swept it. One housekeeper stated they often worked alone, covered all areas of the facility, started upstairs to spot clean, then went to the first-floor units and did the best they could, and confirmed their shift ended mid-afternoon while the second housekeeper’s shift ended later. The Facility Service Manager stated that the facility previously had three housekeepers but now had only two, that he had not assigned specific locations to each housekeeper, and that there was no checklist or assignment log, even though the two housekeepers were responsible for all common areas and resident rooms. The Life Enrichment Director reported that residents had raised concerns about incomplete housekeeping during multiple Resident Council meetings, and the Executive Director acknowledged seeing housekeeping concerns during rounds and confirmed there was no current policy regarding housekeeping services.
Failure to Follow Approved Menu Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure that planned and approved menus, including specified portion sizes, were followed during meal service. Surveyors reviewed the approved lunch menu for 04/14/26, which required #8 scoops (4 oz.) for mashed potatoes, apple crisp, mechanical chicken, ground chicken, carrots, and chef choice vegetables; 2 oz. of gravy; and one chicken cordon bleu for regular diets. The facility’s Portion Control Chart identified the #8 scoop as gray, the #12 scoop (2 2/3 oz.) as green, and the #16 scoop (2 oz.) as blue. During observation of lunch service in the first-floor satellite kitchen, the steam table contained mashed potatoes, gravy, chicken cordon bleu, chef choice vegetables, carrots, apple crisp, and mechanical and ground chicken. Dietary Aide 1 was observed serving chicken cordon bleu mechanical and ground, carrots, and mashed potatoes with the #12 green scoop, and chef choice vegetables with the #16 blue spoodle, resulting in portions that were smaller than those indicated on the approved menu. For the dinner meal on the same date, the approved menu required a #8 scoop (4 oz.) for creamy coleslaw, one grilled cheese sandwich, one chocolate crispy bar, and 6 oz. of tomato soup. During observation of dinner service in the first-floor satellite kitchen, the steam table was set up with tomato soup, creamy coleslaw, grilled cheese sandwiches, and chocolate crispy bars. Dietary Aide 2 was observed serving tomato soup using a 4 oz. ladle instead of the required 6 oz. ladle and confirmed using the smaller ladle, stating they relied on recipes to determine scoop or ladle size. The Registered Dietitian reported that most residents were on regular diets, that portion sizes were documented on weekly menu extensions they approved, and that kitchen staff were expected to follow those approved portions using universal portioning equipment. The Executive Director stated the facility could not locate a policy on following approved menus, while the Dietary Manager acknowledged that the lunch portions on 04/14/26 were underserved and that staff receive periodic training on steam table use and scoop selection. The DON stated it was the expectation that the Dietary department serve meals according to the approved menus. Overall, 53 residents receiving facility-prepared food were affected by these incorrect portion sizes, placing them at risk for weight loss, malnutrition, and dissatisfaction with their meals.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) immediately, but no later than two hours after the allegation was made, as required by facility policy and federal and state law. The facility’s abuse policy stated that all alleged violations involving abuse must be reported immediately, but not later than two hours, to the Executive Director and to appropriate officials, including the State Survey Agency. A cognitively intact resident, admitted with anxiety disorder and metabolic encephalopathy and without a documented pressure ulcer on the admission MDS, reported through a grievance that a CNA had taken a picture of her buttocks wound on a personal phone. The grievance form documented that the resident reported the CNA took a picture of her buttocks wound on or about early January and that the facility investigated by interviewing the CNA, who stated she had only shown the resident a Google image of a similar but worse buttocks wound to illustrate the impact of wearing briefs at night and denied taking a photo of the resident. The grievance was documented on the facility’s Report of Grievance and on the Grievance Log, but review of Facility Report Investigations (FRIs) showed no evidence that this allegation was reported to the SA. Social Services staff confirmed that the interdisciplinary team determined the situation was not abuse and therefore did not report it to the SA within two hours. The DON was unable to state what types of incidents must be reported to the SA within two hours, and the Admissions/Former Administrator confirmed that the grievance was not viewed as an allegation of abuse because staff accepted the CNA’s explanation that she had only been talking with the resident and had not taken a photo. The Admissions/Former Administrator further indicated that incidents and grievances were reported depending on how they were investigated and that each situation was handled individually, resulting in this allegation not being reported as required.
Failure to Thoroughly Investigate Allegation of Abuse Involving Resident Photograph
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident when a grievance was filed stating that a CNA had taken a picture of the resident’s buttocks wound. The facility’s abuse policy required that all reports of abuse be promptly and thoroughly investigated through the QAPI incident report and investigation process, including identifying who was involved, obtaining resident statements, and obtaining statements from involved staff and witnesses, as well as protecting residents from alleged offenders. The resident involved had been admitted with anxiety disorder and metabolic encephalopathy and had a BIMS score of 15/15 on the admission MDS, indicating intact cognition, with no documented psychosis, behavioral symptoms, or resistance to care. A facility grievance report documented that the resident reported the CNA took a picture of her buttocks wound on or about early January. During the facility’s handling of the grievance, the CNA denied taking a picture and stated she had only shown the resident a Google image of a similar but worse buttocks wound to explain the consequences of not following the intervention of not wearing briefs at night. Social services staff reported that they interviewed the CNA and multiple staff members as part of the grievance investigation but confirmed there was no documentation of these interviews, and no residents were interviewed. The former administrator did not provide any evidence that an investigation had been conducted, and the current administrator refused to answer surveyor questions about the grievance. The facility was unable to produce documentation of an investigation as required by its abuse policy.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate pressure ulcer prevention and care for two residents identified as at risk for pressure injuries. One resident was admitted without pressure injuries but was at risk due to immobility, incontinence, and other medical conditions. The Braden Scale assessment for this resident was inaccurately completed, and required weekly assessments were not performed as per facility policy. No preventive care plan interventions, such as offloading, scheduled turning and repositioning, or incontinence management, were implemented initially. The resident subsequently developed a facility-acquired unstageable pressure injury, which became infected and required advanced wound care, including debridement, antibiotics, and a wound vacuum. The care plan was not updated with new interventions after the injury was identified, and recommended treatments were not consistently completed as ordered. There was also a documented incident where the resident was not checked or changed for an entire night shift, and this lapse was not immediately addressed in the care plan. Another resident, also identified as at high risk for pressure injuries due to immobility and cognitive impairment, did not have care plan interventions for offloading heels implemented as observed by the surveyor. Despite care plan instructions and documentation in the Kardex for heel offloading, repeated observations showed the resident's heels were not offloaded and were pressed against the footboard. Staff interviews revealed that refusals of care by the resident were not consistently documented, and there was no care plan in place for managing refusals until after the survey began. The lack of documentation and implementation of preventive interventions persisted over multiple observations. The facility's policy required risk assessments, identification and implementation of interventions, and regular care plan updates based on changes in condition or the development of pressure injuries. However, these procedures were not followed for both residents. The surveyor found that the facility did not ensure care and services were provided according to professional standards to prevent pressure injuries, nor did it ensure necessary treatment and services were provided to promote healing and prevent new ulcers from developing.
Removal Plan
- A facility-wide skin sweep audit was completed for all in house residents to identify anyone with existing or potential pressure injuries.
- Residents Braden assessments were completed for all in house residents.
- Pressure ulcer prevention interventions were verified for all at-risk residents, including care plan updates if needed. If a new intervention was needed, it was implemented.
- Reviewed the Illuminus policy to ensure compliance with CMS and Wisconsin DBS guidance.
- Re-educated all nursing staff on proper process for staging wounds and the required weekly documentation of each wound and an entered intervention.
- Re-educated all nursing staff on pressure injury prevention and skin integrity, including accurate and timely documentation of skin assessments and treatments.
- Re-educated all nursing staff on importance of repositioning, offloading, and movement.
- Facility will audit up to 4 residents with wounds a week, focusing on proper staging and documentation.
- DON and/or designee will be responsible for these audits. All results will be reported to QAPI committee for future action or adjustment.
- Practice is to follow National Pressure Ulcer Advisory Panel Standards along with the Critical Element Pathway for pressure injuries.
- WCC nurse is credentialed by the wound care educational institute.
Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Fall Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents reviewed for accidents. One resident experienced ten unwitnessed falls, with three of these incidents not being thoroughly investigated for root cause. The majority of these falls occurred when the resident attempted to ambulate to the bathroom independently. Despite being identified as high risk for falls through multiple assessments, the facility did not consistently implement or document fall prevention interventions such as 30-minute checks, urinal at bedside, or the use of non-skid footwear. Additionally, staff statements were not always obtained during fall investigations, and neurological checks were sometimes omitted. The facility also did not conduct a bowel and bladder assessment to establish a toileting pattern, which could have addressed the repeated falls related to bathroom needs. Another resident's fall was not thoroughly investigated, and several fall prevention interventions were not implemented at the time of the incident. The resident was found on the floor without appropriate footwear, and staff failed to ensure the call light was within reach. The care plan required staff to assist with brushing teeth after lunch, maintain a toileting schedule, and use a gait belt for transfers, but these interventions were not observed to be in place. Staff statements regarding the fall were incomplete, and there was a lack of documentation from key personnel who were present at the time of the incident. A third resident was observed with the call light out of reach and was given straws despite having an aspiration risk. These observations occurred during the survey process and were contrary to the resident's care plan and safety requirements. The facility's failure to implement and monitor individualized interventions, conduct thorough investigations, and ensure staff adherence to care plans contributed to the deficiencies in accident prevention and resident safety.
Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
Surveyors found that the facility failed to ensure timely reporting of allegations of abuse, neglect, and misappropriation involving seven residents to the State Survey Agency, as required by federal and state law. Multiple grievances were filed by residents or their representatives, each containing allegations of neglect or misappropriation, but none of these were reported to the appropriate authorities within the mandated timeframes. The facility's own policies require immediate or 24-hour reporting of such allegations, depending on the severity, but these procedures were not followed. Specific incidents included residents reporting not being changed for extended periods, having to wait excessive times for call lights to be answered, and being left in soiled conditions overnight. In one case, a resident's representative reported that the resident was not cleaned up after a bowel movement until late in the morning, and another grievance involved a staff member refusing to assist a resident after responding to a call light. Additionally, an allegation of misappropriation was made when a resident was observed giving money to kitchen staff, but this was also not reported to the State Agency. Interviews with facility staff, including the Life Coach and Director of Nursing, revealed a lack of clarity and understanding regarding what constitutes reportable abuse or neglect. Staff admitted to not always knowing when to escalate grievances to administration for reporting. Despite being made aware of the allegations and the facility's policy requirements, no explanations were provided by facility leadership for the failure to report these incidents to the State Survey Agency.
Failure to Thoroughly Investigate Allegations of Neglect and Misappropriation
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate multiple allegations of neglect and misappropriation involving seven residents. These allegations included residents not being changed for extended periods, long wait times for call light responses, and a report of possible misappropriation of resident property. In each case, the facility did not obtain staff statements or interview other residents to determine if there was a pattern of neglect or if other residents were affected. The facility's own policies require thorough investigation and reporting of such allegations, but these procedures were not followed. Specific incidents included residents reporting not being changed for hours, having to wait until the next shift for assistance, and being left in soiled conditions overnight. In one case, a resident's representative reported that the resident was not cleaned up after a bowel movement until late in the morning, with staff citing being too busy. Another resident's representative reported that a CNA told the resident they could not help at that time, resulting in a long wait for assistance. In the case of alleged misappropriation, the investigation was limited to brief observations and informal conversations, without formal staff interviews or broader resident interviews to assess the scope of the issue. Interviews with facility staff, including the Life Coach and Director of Nursing, revealed a lack of clarity and consistency in the investigation process. Staff members were sometimes unsure of their roles or the definitions of neglect and abuse, and in some cases, the person assigned to investigate did not actually conduct the investigation. Documentation was incomplete, and there was no evidence that the facility took steps to determine if other residents were affected by the same staff members implicated in the allegations.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that all direct care staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. During a survey, it was found that five randomly selected certified nursing assistants (CNAs) did not have documentation of QAPI training as part of their new hire orientation. The nursing home administrator (NHA) confirmed that the facility uses an online training platform, Relias, for staff education, but transcripts for the selected CNAs did not show completion of QAPI training. The facility's training plan, as outlined in the Facility Assessment, did not include QAPI among the required topics for staff education and competency verification. Further investigation revealed that the process for tracking staff training completion relied on corporate communication, with the NHA depending on emails from a corporate employee to identify outstanding education requirements. When questioned, the corporate employee acknowledged a gap in QAPI training and stated that the module was only assigned to all staff for the fourth quarter of the current year, rather than upon hire. As a result, the five CNAs had not received QAPI training at the time of the survey, potentially affecting all 43 residents in the facility.
Failure to Notify Emergency Contact After Resident Falls
Penalty
Summary
The facility failed to notify a resident's emergency contact or representative following two separate unwitnessed falls that occurred on 6/30/25 and 7/12/25. According to the facility's policy, any change of condition, including falls, requires timely notification of the resident's representative. Review of the electronic medical record and fall investigations revealed no documentation that the resident's wife or emergency contact was informed of either incident or the potential change in condition. The resident, who had a history of hemiplegia, atherosclerotic heart disease, chronic kidney disease, COPD, epilepsy, anemia, dysphagia, and depression, was assessed as moderately impaired in daily decision-making but was alert and oriented at the time of surveyor interviews. During interviews, the resident expressed that his wife should be notified of all events at the facility. The DON stated that notification was not necessary because the resident was considered his own person at the time, but there was no documentation indicating the resident declined notification of his emergency contact. The surveyor confirmed with facility leadership that there was no evidence or explanation provided for the lack of notification, despite facility policy requiring it.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, severe cognitive impairment, and a history of stroke was not provided with necessary assistance for activities of daily living (ADLs), specifically in maintaining proper grooming and nail care. The resident's care plan and facility policy required that fingernails be kept short and clean, with nail trimming to occur on bath or shower days and as needed. Despite these documented interventions, the resident was repeatedly observed by surveyors to have extremely long and dirty fingernails on all fingers of both hands over multiple days during the survey process. The resident's medical record indicated a need for partial to moderate assistance with hygiene and personal care due to significant physical and cognitive limitations. The care plan and Kardex both instructed staff to keep the resident's fingernails short to avoid scratching and protect skin integrity. However, observations made by the surveyor on several occasions showed that this care was not provided, and facility leadership was unable to provide an explanation for the failure to perform the required ADL assistance. No additional information was provided by the facility regarding why the resident's nail care was neglected.
Failure to Provide Timely Assessment, Follow Physician Orders, and Complete Neurological Checks
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for three out of four residents reviewed. In one case, a resident with multiple diagnoses, including chronic respiratory failure, dementia, atrial fibrillation, and anxiety disorder, was receiving anticoagulant therapy and sustained an unwitnessed fall resulting in a head injury and a skin tear. The initial assessment was incomplete, as the nurse practitioner only assessed range of motion and did not return to complete a comprehensive assessment until several hours later. There was no registered nurse assessment documented, and neurological checks were not performed according to policy, with one of the required 30-minute checks missed. When the ambulance arrived, staff were unable to provide a timely and complete report, and the resident was not sent to the hospital until several hours after the fall, despite being on blood thinners and having a head injury. In another instance, the facility did not follow a physician's order to obtain a stool sample to test for Clostridioides difficile for a resident. The order was documented in the treatment administration record, but there was no evidence that the sample was obtained or sent to the lab, nor was there any documentation in the resident's medical record regarding the order. The infection control nurse and nursing home administrator were unaware of the order, and no follow-up was documented. Additionally, the facility failed to complete and document neurological checks for another resident who experienced two unwitnessed falls. The facility's policy required neurological checks to be performed at specific intervals following such events, but there was no documentation that these checks were started or completed. The director of nursing confirmed the absence of documentation, and staff acknowledged that neurological checks should have been performed for unwitnessed falls.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
A resident with chronic respiratory failure, COPD, and hypoxia, who is dependent on supplemental oxygen, did not receive oxygen therapy as ordered by the physician. The physician's order specified oxygen at 2 liters per nasal cannula to maintain oxygen saturation at or above 95%. However, observations revealed that the resident's oxygen concentrator was frequently set at 3.5 liters, exceeding the prescribed amount, and the oxygen tubing was not one continuous piece as required by an intervention following a previous incident. Instead, two oxygen tubes were connected together, contrary to the facility's stated intervention to prevent disconnection. On one occasion, the resident was found with disconnected oxygen tubing, resulting in an oxygen saturation of 80%. The ambulance crew discovered the disconnection at the connector, and the facility determined that the likely cause was the resident moving in bed and pulling the tubing apart. Despite this, subsequent observations showed that the resident continued to receive oxygen through two connected tubes, and the care plan was not updated to reflect the intervention of using a single continuous tube. Staff members, including a CNA and LPN, were observed providing care without adjusting the oxygen flow to the ordered rate, and the LPN was unaware of the correct physician order until informed by the surveyor. Additionally, the facility's care plans for oxygen therapy and respiratory conditions were not revised to include the intervention of using a single continuous tube, as discussed by the interdisciplinary team after the hypoxic incident. Multiple staff members failed to ensure the resident received oxygen at the prescribed rate and with the correct tubing setup, as evidenced by repeated surveyor observations and staff interviews.
Failure to Administer Ordered Medication Due to Lapses in Medication Management
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including depression, was not administered Mirtazapine as ordered. The resident was cognitively intact and had an active prescription for Mirtazapine 15 mg to be given at bedtime. The Medication Administration Record (MAR) showed that the medication was not given on three specific dates, and there was no documentation in the progress notes explaining the missed doses. The facility's policy requires that if a medication cannot be located, staff should search other areas and contact the pharmacy or use the emergency kit, but there was no evidence these steps were taken. Pharmacy records confirmed that a supply of Mirtazapine was sent to cover the period up to a certain date, with the next supply sent after a gap. During the gap, no doses were removed from the contingency supply, and the pharmacy was not contacted for a refill as per protocol. The facility was unable to provide additional information regarding the missed doses when questioned by the surveyor. This failure resulted in the resident not receiving the prescribed medication as ordered.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin (IUO) within the required timeframe to the State Survey Agency for a resident who was moderately cognitively impaired and had diagnoses including spastic hemiplegia and quadriplegia. The resident complained of right ankle pain and was sent to the hospital, where a closed fracture of the right ankle was diagnosed. The x-ray report indicated the age of the fracture was undetermined. Upon return from the hospital, the resident was given an order for oxycodone for pain management. Documentation shows that the incident was reported to the Director of Nursing (DON) in a timely manner by the LPN, and the Administrator was also informed. However, the facility did not submit the Misconduct Incident Report to the State Survey Agency until five days after the injury was first identified. The delay occurred because the Interim Administrator was unsure if the event was reportable and wanted to gather additional information before submitting the report.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with significant physical and cognitive impairments. The resident, who had spastic hemiplegia and quadriplegia and was moderately cognitively impaired, complained of right ankle pain and was subsequently diagnosed with a closed fracture after being sent to the hospital. Documentation revealed that not all staff involved in the resident's care prior to the diagnosis were interviewed or asked to provide statements during the investigation. Interviews with staff who had direct knowledge of the resident's complaints of ankle pain prior to the diagnosis confirmed they were not included in the investigation process. Additionally, the resident reported that the injury occurred during a manual transfer performed by staff without proper assistance or equipment. The facility's investigation concluded that the most likely cause of the fracture was improper transfer by staff, but this could not be verified due to incomplete staff interviews and documentation.
Resident Excluded from Person-Centered Care Planning
Penalty
Summary
A deficiency was identified when a resident was not allowed to participate in the development and implementation of their person-centered plan of care. The report notes that the facility failed to ensure the resident's involvement in planning their care, which is a required aspect of person-centered care. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Revise Care Plan for Denture Storage After Multiple Losses
Penalty
Summary
The facility failed to revise the care plan for a resident with severe cognitive impairment and an activated healthcare power of attorney to address the safe storage of the resident's dentures, despite multiple incidents of the dentures being lost. The resident, who requires partial assistance with activities of daily living and has a history of hemiplegia, hemiparesis, vascular dementia, and anxiety, had a care plan that only included reminders to put on and remove dentures but did not specify interventions for their secure storage. Nursing documentation indicated that the dentures were lost on two separate occasions, with the facility only able to recover them after the first incident. Interviews with staff revealed inconsistent practices regarding denture storage, with options including keeping dentures in the resident's bathroom or in the medication cart, depending on resident or family preference. Despite these incidents and the facility's policy requiring care plans to be reviewed and revised as needed, the care plan was not updated to include specific interventions for denture storage. The deficiency was identified during a survey when it was noted that the care plan did not reflect the resident's needs and preferences regarding denture management.
Failure to Prevent Unnecessary Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Delay in Initiation of Ordered Therapy Services
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, anxiety, chronic heart failure, COPD, and diabetes was not provided with timely physical therapy (PT) and occupational therapy (OT) services as ordered. The resident, who had severe cognitive impairment and an activated healthcare power of attorney, was admitted with significant functional needs and had previously been discharged from OT and PT after reaching a plateau. On 4/29/25, new physician orders were written to initiate PT and OT, but these services were not started until 7/14/25. During this period, there were no progress notes or documentation in the electronic health record (EHR) indicating that therapy services had been initiated or evaluated as per the new orders. Staff interviews revealed that the therapy department typically relies on notification from the in-house nurse practitioner for new therapy orders, but in this case, the resident's physician was external. The Director of Rehab (DOR) acknowledged responsibility for the delay, stating that the therapy order was overlooked until the Nursing Home Administrator (NHA) brought it to their attention after the resident's power of attorney requested therapy. The nurse supervisor confirmed that new orders should be transcribed into the EHR, but was unable to locate the therapy orders in the appropriate section. The facility did not have a policy or procedure for following physician orders or for initiating rehabilitation services when ordered, contributing to the delay in providing required therapy services.
Failure to Provide Adequate Pressure Injury Care
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents with pressure injuries, leading to a finding of immediate jeopardy. Resident R147 developed moisture-associated skin damage (MASD) and a stage 4 pressure injury that required debridement. The facility did not revise the care plan or conduct comprehensive assessments to address R147's pressure injuries, nor did they assess the appropriateness of the wheelchair cushion and mattress being used. This lack of individualized care and assessment contributed to the worsening of R147's condition. Resident R350 was admitted with a stage 3 pressure injury to the right buttock and a stage 1 pressure injury to the left heel. Despite being at risk for pressure injuries, preventative interventions were not observed being implemented for R350. The facility's failure to implement necessary preventative measures and revise care plans for residents at risk of pressure injuries was a significant deficiency. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of comprehensive assessments, care plan revisions, and appropriate interventions for residents R147 and R350. The facility's inaction and failure to adhere to professional standards of practice resulted in immediate jeopardy for R147, highlighting a critical deficiency in the care provided to residents with pressure injuries.
Removal Plan
- Resident has resolving pressure injury to right heel and stable stage four PI to sacrum - goals of care are currently being met.
- Skin sweep completed to ensure all skin altercations have been identified, documented and have appropriate treatments and interventions in place.
- Care plan sweep completed to ensure all interventions are individualized (guided by skin sweep results).
- All staff educated on standard skin protocol. This includes skin integrity monitoring and change expectations for nurses, aides, dietary and therapy.
- All licensed nurses educated on standard skin protocol, and comprehensive wound documentation expectations - including upon admit and recognition of a new skin altercation the licensed nurse will: alert provider and obtain any needed treatment orders, document comprehensive skin observation, interventions to be placed and documented as appropriate for resident, update DON or designee, update POA if applicable; and complete Risk Management for any new skin altercation, competency quiz to validate understanding.
- All nurse managers educated on PI (pressure injury) CEP and comprehensive wound system- this will include daily in stand-up clinical leader to review progress notes, RM, 24 hours boards to ensure all new skin altercations addressed appropriately including assessment and implementation of support surface, along with update to RD and wound team, to ensure compliance of F686.
- Facility skin sweep done.
- All skin care plans updated and individualized per skin sweep observations which included support surface assessments and updates.
- Weekly comprehensive wound rounds to continue with RN and NP.
- Skin care plans will be reviewed weekly with clinical IDT focus meeting to ensure support surface interventions, and weekly wound rounds to validate appropriate support surfaces in place.
- Standard Skin Protocol reviewed and updated.
- Skin policy and procedure reviewed.
- Updated and reviewed citation with Medical Director.
- DON or designee will audit five residents weekly for comprehensive skin system compliance. Results to QAPI (Quality Assurance and Performance Improvement).
Failure to Provide Appropriate Care and Treatment for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R297, in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. R297 was admitted with several diagnoses, including depression, diabetes mellitus, and Alzheimer's Disease, and had an order for wound care on the left shin. However, there was only one documented skin assessment of this area, and no further assessments were conducted despite the continuation of treatment until August 1, 2024. Additionally, there were no assessments or documentation regarding the application of dressings on R297's left lower extremity, as noted by an Advanced Practice Nurse Prescriber on July 22, 2024. On July 28, 2024, R297's left forearm was noted to be bruised and red due to a tight watch, which later changed to scabbing by August 1, 2024. Despite these changes in skin integrity, no comprehensive skin assessments were conducted. Furthermore, on August 13, 2024, R297 experienced a change in condition, including a significant decrease in meal intake and altered mental status, but there was no comprehensive assessment or timely intervention. A urinalysis was ordered without prior assessment or vital signs, and although R297 had an order for acetaminophen for fever, it was not administered before the resident was transported to the hospital. The facility's policy on Change of Condition and Provider Notification was not followed, as there was a lack of comprehensive assessment and timely intervention by licensed nurses. The resident was eventually admitted to the hospital with sepsis and a urinary tract infection, and later passed away due to MRSA bacteremia and related complications. Interviews with facility staff revealed inconsistencies in communication and documentation, contributing to the failure to provide appropriate care and treatment for R297.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents, particularly falls, among residents. Several residents, including those with severe cognitive impairments and high fall risks, experienced falls that were not thoroughly assessed for causative factors. The facility's fall interventions were not consistently implemented or monitored, as evidenced by the lack of thorough investigations and missing documentation of whether prior interventions were in place at the time of the falls. For instance, one resident with vascular dementia and on hospice care had multiple falls, yet the facility's investigations did not include staff statements or evidence that prior interventions, such as the use of a body pillow, were in place. Another resident with congestive heart failure and severe cognitive impairment also experienced multiple falls. The facility's investigations into these incidents were incomplete, lacking staff interviews and documentation of whether fall prevention measures were in place. In one instance, the resident sustained a head injury, yet there was no confirmation if a gait belt was used during the transfer, as required by the care plan. Additionally, the facility failed to ensure that the resident's call light was within reach, which is a critical intervention for fall prevention. A third resident, with a history of spastic hemiplegia and dementia, was observed multiple times with the call light out of reach, despite being at risk for falls. The facility staff failed to place the call light within reach after providing care, such as delivering meals or performing wound care. This oversight was noted by the surveyor, who informed the facility's administration of the repeated observations. The lack of adherence to the care plan interventions and inadequate investigation into fall incidents highlight significant deficiencies in the facility's fall prevention and supervision protocols.
Failure to Designate Charge Nurse on Each Shift
Penalty
Summary
The facility failed to designate a licensed nurse to serve as a charge nurse on each shift, as required. This deficiency was identified through observation, interview, and record review. The surveyor requested nursing schedules and nurse staff postings for Quarter 4 of 2024 and for the period from January 20 to February 10, 2025. Upon review, it was noted that the facility's nursing schedules did not specify who the charge nurse was for each shift. During an interview, the scheduler responsible for coordinating the nursing schedule and preparing staff postings admitted to being unaware of the requirement to designate a charge nurse for each shift. The Nursing Home Administrator was informed of this issue, but no additional information was provided to explain the lack of designation.
Sanitation Deficiencies in Food Preparation and Delivery
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as observed in two food preparation and serving areas and during meal tray service to resident rooms on Unit A. The dish machine in the facility kitchen was not functioning properly to sanitize dishware, and dietary staff were observed without proper hair restraints in both the first-floor kitchen preparation and serving area and the main kitchen. Additionally, meal trays delivered to resident rooms on Unit A had items that were not covered during delivery. On multiple occasions, dietary staff were observed not adhering to the facility's policy on hair restraints. For instance, Dietary Aide (DA)-V was seen with an uncovered medium-length beard while setting up meal trays, and DA-X had a hairnet that did not cover their entire head. The Food Service Director (FSD)-W was unaware of the dates of the policy and procedures in use, which lacked a review or revision date. The facility's policy required all staff entering the kitchen to wear hairnets or hair restraints, but this was not consistently followed. The dish machine logs were incomplete, with missing temperature documentation for several months, indicating a lack of monitoring to ensure proper sanitization. The logs did not include temperature documentation for each meal use, and there was no backup system to verify that the dish machine was sanitizing correctly. Additionally, during meal tray delivery to resident rooms, items such as cereal, fruit, and other side items were not covered, contrary to the facility's policy that only the hot meal should be covered. This practice was observed multiple times, with trays being carried down hallways with uncovered items, raising concerns about maintaining sanitary conditions during food distribution.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Review of daily staff postings and nursing schedules for multiple months revealed that on numerous dates, there was no RN present in the facility for the required duration. Specific dates in July, August, September 2024, as well as January and February 2025, were identified where the facility did not have an RN on duty for 8 consecutive hours. This deficiency was confirmed through documentation and staff interviews. During an interview, the scheduler acknowledged ongoing difficulties in finding enough RNs to cover all required shifts. It was noted that the Director of Nursing (DON) was present most days and could act as the covering RN, but this was not consistently reflected in the facility's schedules, particularly on weekends. No further explanation was provided for the failure to ensure RN coverage as required. All 49 residents in the facility were potentially affected by this deficient practice.
Deficient Infection Control and Water Management Practices
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, as evidenced by multiple deficiencies in their water management and infection surveillance practices. The facility did not have a current, detailed water management plan specific to its building, including flow charts and identification of areas of concern such as dead legs in the water system. The Facilities Services Manager was unaware of the existence or location of dead legs, had not performed or documented flushing of these areas, and did not maintain records of temperature monitoring or visual inspections for biofilm. Documentation of interventions, such as flushing unused rooms and monitoring water temperatures, was either generic or absent, with most information kept in the manager's memory rather than in written logs. The water management plan was not included in the facility assessment, and there was no evidence of regular review or discussion of water management in Quality Assurance or Infection Control committees. The infection control program also lacked the use of baseline infection rates to analyze prevalent infections and did not comprehensively track interventions or analyze outcomes for two outbreaks that occurred in the facility. During interviews, the Assistant Director of Nursing/Infection Preventionist was unable to provide detailed timelines or evaluations of the outbreaks, including when interventions were implemented, the effectiveness of those interventions, or any quality improvement analysis following the outbreaks. Documentation provided was limited to line lists with start and resolution of symptoms, without comprehensive tracking or analysis. The facility assessment did not address how the combined role of Assistant Director of Nursing and Infection Preventionist was delineated. Additionally, staff failed to utilize proper hand hygiene when entering or leaving the room of a resident on enhanced barrier precautions. This lapse in infection control practice was observed and noted as a direct deficiency. The combination of these failures in documentation, monitoring, and adherence to infection control protocols had the potential to affect all 49 residents residing in the facility.
Failure to Provide Resident-Preferred Bedtime Gowns Due to Linen Shortage
Penalty
Summary
A deficiency occurred when the facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring the availability of hospital gowns for residents who preferred to wear them at night. One resident, who was cognitively intact and had multiple medical diagnoses including hypothyroidism, type 2 diabetes, obstructive sleep apnea, hypertension, and a femur fracture, reported not having access to a hospital gown for several consecutive nights. The resident expressed a clear preference for wearing a gown to bed but was told by staff that none were available, resulting in the resident sleeping in the same shirt worn during the day. Multiple observations by the surveyor confirmed the absence of gowns on the linen carts across all units during this period. Staff interviews corroborated that gown shortages occurred at times, and the Facility Services Manager (FSM) explained that linens, including gowns, were managed by an offsite contractor and delivered on a set schedule. Documentation and interviews revealed that no gowns were delivered or available in the facility from Friday through Tuesday, and the FSM could not account for the lapse in supply. The linen contract outlined procedures for addressing deficiencies, but no evidence was provided that these were followed during the shortage. The deficiency was confirmed by direct observation, staff statements, and review of linen delivery records.
Failure to Develop Urinary Care Plan Post-Catheter Removal
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed for a resident after the discontinuation of their Foley catheter. The resident, who was admitted with diagnoses including depression, benign prostatic hyperplasia, urinary retention, diabetes mellitus, and Alzheimer's Disease, had their Foley catheter removed on June 7, 2024. Despite this significant change in the resident's condition, the facility did not develop a urinary care plan to address the resident's needs post-catheter removal. This oversight was identified during a survey, which noted that the facility's policy required care plans to be reviewed and revised upon a change of condition. The resident's medical records indicated a history of severe cognitive impairment and other health issues, necessitating careful management of their urinary needs. However, after the catheter was removed, there was no documented care plan to monitor and manage the resident's urinary continence. The Director of Nursing acknowledged that a urinary care plan should have been developed by nursing management or MDS staff, but it was not. This lack of action led to the deficiency noted by the surveyor, as the facility did not adhere to its own policy of updating care plans following significant changes in a resident's condition.
Failure to Assess and Authorize Self-Administration of PRN Inhaler
Penalty
Summary
A deficiency occurred when a resident was allowed to keep a PRN Albuterol inhaler in their bedside drawer without the required interdisciplinary team assessment or a physician order authorizing self-administration. The facility's policy mandates that residents who wish to self-administer medications must first be assessed for their cognitive, physical, and visual abilities, and a prescriber's order must be obtained. However, the resident's electronic medical record did not contain documentation of a self-administration assessment or a physician order for bedside storage and self-administration of the inhaler at the time of the survey. The resident, who was cognitively intact and had diagnoses including asthma and hypertension, explained to the surveyor that they kept an emergency Albuterol inhaler at the bedside, separate from another inhaler stored in the medication cart. The deficiency was confirmed through observation, interview, and record review, with facility leadership acknowledging that the required assessment and order were missing for the resident to keep and self-administer the PRN inhaler at bedside.
Resident Privacy Breach During Psychiatric Interview in Dining Room
Penalty
Summary
A nurse practitioner specializing in psychiatric/mental health conducted a medical interview with a resident in the facility's main dining room during lunchtime. At the time of the interview, three other residents and a family member were present in close proximity, making it possible for them to overhear the conversation. The nurse practitioner asked the resident a series of questions regarding medications, mood, pain, memory, and personal history, including specific questions about the resident's birthdate and family. The resident, who had a BIMS score of 3 indicating severely impaired decision-making skills, responded to these questions in the presence of others. The facility's policies and resident rights documents require that case discussions, consultations, examinations, and treatments be conducted discreetly and confidentially, ensuring privacy for residents regarding their health care and personal information. Despite these requirements, the interview was not conducted in a private area, and confidential medical information was discussed openly in a communal space. The nurse practitioner later stated that the resident was the only one needing to be seen and did not want to interrupt the resident's lunch, which led to the decision to conduct the interview in the dining room. Additionally, the surveyor observed that the resident's lunch was interrupted and had to be reheated due to the length of the interview. The facility administrator was not initially aware of the incident but acknowledged the concern when informed. The resident later stated that privacy is important but did not recall the interview. Documentation of the psychiatric evaluation was not immediately available in the electronic medical record and had to be requested directly from the nurse practitioner.
Failure to Complete and Review Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, as required by its own policy and federal regulations. For one resident admitted with multiple diagnoses including a left patella fracture, dysphagia, asthma, and hypertension, the baseline care plan was not initiated or reviewed with the resident within the required timeframe. Although focused care plan problems were eventually documented, there was no evidence that these were reviewed with the resident, who was cognitively intact and able to participate in care planning. Interviews with facility staff confirmed that the baseline care plan process was not followed as expected, and the social worker responsible for reviewing the plan with the resident was unavailable during the survey. For another resident admitted with Alzheimer's disease, dementia, and pressure ulcers, the baseline care plan was not completed, signed, or reviewed with the resident's Power of Attorney (POA) within 48 hours of admission. The resident's hospital discharge summary included specific interventions for skin integrity, such as turning every two hours, use of heel lift boots, and an air mattress, but these were not incorporated into the facility's baseline care plan. The skin integrity section of the care plan assessment form was not addressed, despite this being the primary reason for the resident's admission. Staff interviews revealed a lack of clarity and follow-through regarding the inclusion of individualized interventions and timely completion of the care plan. Throughout the survey, facility staff acknowledged that the baseline care plans should have been completed and reviewed within 48 hours, and that individualized interventions from hospital discharge summaries should have been included. However, documentation and interviews confirmed that these requirements were not met for the two residents reviewed, resulting in a deficiency related to the timely development and implementation of person-centered baseline care plans.
Failure to Monitor and Document Catheter Output as Ordered
Penalty
Summary
Facility staff failed to monitor and document urinary catheter output as ordered by physicians and outlined in care plans for two residents with indwelling catheters. Both residents had specific physician orders and care plan interventions requiring catheter output to be monitored and documented three times daily. However, for one resident, there was no documentation of catheter output from early February until mid-February, and for the other resident, no output was documented from the beginning of November until mid-February, except for two isolated nursing notes. Interviews with CNAs, LPNs, the ADON, and the DON confirmed that the expectation was to empty catheter bags and document output every shift, with documentation to be entered in the Treatment Administration Record (TAR) or Medication Administration Record (MAR). Despite this, review of the TARs for both residents showed a lack of documentation for the required periods. Staff were unable to provide explanations for the lack of documentation, and the DON was not aware of the missing records until informed by the surveyor. Facility policy required perineal care, proper positioning of catheter bags, and documentation of output every shift. Observations confirmed that catheter care was being performed, but the critical step of documenting output was not consistently completed as required by physician orders and facility policy. No additional information was provided by the facility to explain the failure to ensure necessary monitoring and documentation of catheter output for these residents.
Failure to Change Oxygen Tubing Weekly as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary respiratory care and services for a resident with diagnoses including interstitial pulmonary disease, heart failure, and chronic respiratory failure with hypoxia. The resident had a physician order for oxygen tubing to be changed and dated every seven days on the night shift. However, multiple observations by the surveyor over several days revealed that the resident's oxygen tubing was dated 12/7/24 and had not been changed weekly as ordered. The facility's policy also required replacement of durable medical equipment as ordered by the physician. During the survey, staff interviews confirmed that the expectation was for weekly tubing changes, but the tubing in use had not been replaced according to the schedule. The surveyor observed the resident receiving oxygen therapy via nasal cannula at 2 liters per minute on several occasions, each time noting the unchanged tubing date. Staff acknowledged the oversight when it was brought to their attention, but no explanation was provided for the failure to follow the physician's order for weekly tubing changes.
Failure to Consistently Complete Dialysis Communication Records
Penalty
Summary
Facility staff did not consistently complete dialysis communication records for a resident with End Stage Renal Disease who required hemodialysis three times per week. The resident's care plan specified that a dialysis binder should accompany the resident for communication between the facility and the dialysis center, and that facility nurses should check and complete the binder on dialysis days. However, review of the resident's medical record and dialysis communication forms revealed multiple instances of incomplete or missing documentation on specified dates, as well as a prolonged period where no communication records were available for review. Interviews with facility staff, including a newly employed RN and the Nursing Home Administrator, confirmed that the expectation was for dialysis communication forms to be completed each time the resident attended dialysis. Despite this, the facility was unable to provide complete records for several dates, and no explanation was given for the missing or incomplete documentation. The deficiency was identified for the only resident in the facility receiving dialysis services at the time.
Failure to Document Monitoring for Anticoagulant Side Effects
Penalty
Summary
A deficiency was identified when the facility failed to ensure adequate monitoring for adverse reactions to high-risk medications for one resident receiving Warfarin, an anticoagulant. The resident had a history of atrial fibrillation, cerebral infarction, and hyperlipidemia, and was prescribed Warfarin on a scheduled basis for chronic embolism and thrombosis. Although the resident's care plan included an intervention to monitor for side effects and effectiveness of the anticoagulant every shift, there was no documentation in the medical record, including Medication Administration Records (MARs) and Treatment Administration Records (TARs), indicating that such monitoring was performed. During interviews, the Director of Nursing confirmed that residents on Warfarin should be monitored for side effects every shift, but acknowledged that there was no documented evidence of this monitoring for the resident in question. The lack of documentation and monitoring was confirmed through review of the resident's electronic medical record, care plan, and medication records, as well as through direct inquiry with facility leadership.
Failure to Accommodate Resident Food Preferences and Meal Ticket Instructions
Penalty
Summary
The facility failed to provide food accommodations and honor meal preferences for three residents, as documented on their meal tickets. One resident, who was cognitively intact and had not been asked about food preferences upon admission, repeatedly received oatmeal for breakfast despite a documented dislike for oatmeal and a stated preference for cold cereal with milk. This resident also did not receive berries as listed on the meal ticket and was given a hamburger instead of the anticipated kielbasa, with staff later explaining the substitution was due to dietary considerations. The resident had to send back unwanted food items and expressed frustration over not being consulted about preferences. Another resident, also cognitively intact, received Denver eggs for breakfast despite a documented dislike for eggs on the meal ticket. The surveyor confirmed the presence of eggs on the tray and retained the meal ticket as evidence. Additionally, all residents received a peanut butter cookie instead of the posted frosted pumpkin bar, and beef barley soup was served instead of the listed French onion soup, with no prior notification to residents about these menu changes. The registered dietitian acknowledged that menu items were substituted without informing residents and noted that there had been multiple substitutions in recent months. A third resident, who was severely cognitively impaired and had an activated POA, did not receive a banana as specified on the meal ticket, despite repeated requests from the POA and staff assurances that the item would be provided. The POA reported that meal trays often did not match the meal tickets, with fruits and vegetables sometimes missing. The surveyor observed that the banana was not provided even after follow-up, and the issue was reported to facility leadership. No additional information or corrective action was provided by the facility regarding these deficiencies.
Failure to Follow Antibiotic Stewardship Program for UTI Treatment
Penalty
Summary
The facility failed to follow its antibiotic stewardship program for a resident who was treated for a urinary tract infection (UTI) without meeting the established criteria for infection. According to the facility's policy, staff are required to use McGeer's criteria for infection identification, and the CDC's guidelines emphasize reducing antibiotic use in cases of asymptomatic bacteriuria (ASB). Despite these protocols, a resident with a history of urinary retention, obstructive and reflux uropathy, neuromuscular bladder dysfunction, and an indwelling Foley catheter was prescribed and administered antibiotics for a UTI. The resident, who was also receiving hospice services, had a Foley catheter in place and was noted to have concerns of burning in the bladder. A urinalysis was collected after the family requested testing, and the nurse practitioner subsequently ordered antibiotics. Nursing notes throughout the antibiotic course documented that the resident was alert, responsive, and did not report pain or discomfort, with no adverse reactions to the antibiotic noted. There was no documentation of symptoms or findings that would meet McGeer's criteria for a UTI, and the facility's infection preventionist confirmed that the required McGeer's form was not completed for this resident. When questioned by the surveyor, the Assistant Director of Nursing/Infection Preventionist stated that the antibiotic was ordered at the family's request and that the resident did not meet the facility's definition of infection for UTI treatment. No additional information was provided to justify the use of antibiotics according to the facility's established criteria, resulting in a deficiency for not adhering to the antibiotic stewardship program.
Inaccurate Daily Nurse Staff Postings
Penalty
Summary
The facility failed to ensure that daily nurse staff postings accurately reflected the correct number of staff members, including CNAs, Medication Technicians, LPNs, and RNs, for each shift. This issue was identified through a review of nursing schedules and staff postings for Quarter 4 and a specific period in early 2025. The surveyor found discrepancies between the actual number of staff working and the numbers posted on the daily nurse staff postings. During interviews, the scheduler responsible for preparing the nurse staff postings was unaware of any inaccuracies, and the nursing home administrator did not provide an explanation for the failure to ensure accurate postings. The deficient practice had the potential to affect all 39 residents residing in the facility, as the required information was not posted accurately on a daily basis.
Failure to Perform Ordered Post Void Residuals
Penalty
Summary
The facility failed to provide quality care in accordance with physician orders for a resident diagnosed with benign prostatic hyperplasia (BPH). The resident was admitted with a physician order to obtain a post void residual (PVR) every shift. However, the facility did not perform the PVRs as ordered. The resident's medical records, including the Treatment Administration Record (TAR), did not document any PVRs being completed from the specified dates, except for one instance prior to the order. Interviews with the Registered Nurse (RN) and the Director of Nurses (DON) revealed that the order for PVRs was not transcribed into the TAR, leading to the omission of the required procedure. The resident, who was alert and oriented, occasionally complained of urinary frequency but did not report abdominal pain. The Nurse Practitioner (NP) was unaware that the PVRs had not been completed as ordered and expected to be notified if there were issues with completing the PVRs or if the results were abnormal. The failure to perform the PVRs as ordered was attributed to the oversight in transcribing the physician's order into the TAR, resulting in the nursing staff not carrying out the necessary assessments.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as R4, who was admitted with severe back pain following lumbar decompression surgery. Upon admission, R4's pain was rated at a 10, the highest level, and she required Oxycodone for relief. However, due to a delay in obtaining the necessary authorization code from the pharmacy to access the narcotic medication, R4 experienced severe pain for approximately 3.5 hours. During this time, she was only offered Tylenol, which she declined, and no alternative pain management strategies were implemented. The Licensed Practical Nurse (LPN) on duty did not notify the on-call Nurse Practitioner (NP), the Director of Nursing (DON), or consult with other nursing staff regarding the delay in accessing the Oxycodone. The LPN attempted to contact the pharmacy but was informed of a two to four-hour wait for a callback, which was not communicated to the DON until much later. The pharmacy had a hard copy of the Oxycodone prescription but lacked the resident's location information, which delayed the process further. The pharmacy's on-call service attempted to reach the facility multiple times without success until late in the evening. The delay in pain management resulted in R4 experiencing significant distress and discomfort. The facility's failure to follow its pain management policy, which included consulting the medical provider if pain interventions were ineffective, contributed to the deficiency. The DON confirmed that the evening nurse did not notify the pharmacy in a timely manner and failed to escalate the issue to ensure R4 received the necessary pain relief promptly.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Menomonee Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Menomonee Falls Health Services | 0 mi | — | 1 | 0 |
| Congregational Home, Inc. | 5.1 mi | — | 0 | 0 |
| Luther Manor | 5.4 mi | — | 17 | 0 |
| Complete Care At Germantown | 5.6 mi | — | 0 | 0 |
| Amethyst Health Of Brown Deer | 5.9 mi | — | 54 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.