Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Mukwonago during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls did not receive required supervision and assistance devices, specifically Dycem on the wheelchair cushion, as outlined in the care plan. Multiple observations confirmed the absence of Dycem, and staff were unaware of its use. After the resident experienced a fall, the facility's investigation was incomplete, lacking staff statements and a root cause analysis.
A resident with severe cognitive impairment was found with a bruise of unknown origin. Staff assessed the injury and notified the appropriate parties, but the NHA experienced technical issues that delayed the submission of the required five-day follow-up report to the State Agency. As a result, the final investigative findings were not reported within the mandated timeframe, violating reporting procedures.
A resident with severe cognitive impairment was found with a bruise on the forearm, and the facility's investigation was limited to interviews with the CNA who discovered the bruise and the RN who assessed it. The facility did not interview all staff who worked with the resident during prior shifts, as required by policy for injuries of unknown origin. This incomplete investigation led to a deficiency for not thoroughly addressing a potential abuse concern.
A resident with severe cognitive impairment and an activated HCPOA was not given the opportunity to participate in the development and implementation of their person-centered care plan. Despite multiple grievances and the facility's expectation to include activated HCPOAs in care conferences, there was no documentation that the HCPOA was invited or participated in two quarterly care conferences.
A facility did not thoroughly investigate an allegation of neglect involving a CNA and a resident, as only a portion of residents who may have had contact with the CNA were interviewed. Required reports were submitted, but the investigation did not include all potentially affected residents, and staff were unaware of the need to interview everyone involved.
Two residents with significant medical needs, including pressure injuries and dementia, repeatedly refused essential care and treatments such as wound assessments and use of heel boots. Despite documented refusals and staff awareness, the facility did not develop or implement care plans addressing these refusals, as confirmed by interviews with the DON and review of care records.
The facility failed to maintain sanitary conditions in its kitchens, with contaminated air vents, improperly stored food, and non-operational dishwashing equipment. Staff did not adhere to infection control practices, such as using hair restraints and proper hand hygiene, potentially affecting all 39 residents.
A resident's DNR status was not accurately reflected in the EHR for 19 days, despite being signed and filed in the paper chart. Staff relied on inconsistent sources to determine code status, leading to confusion. The discrepancy was discovered during a surveyor's review, revealing a gap in the facility's documentation procedures.
A resident with COPD, sleep apnea, and panic disorder continued to receive clonazepam beyond the original 14-day order due to a failure to transcribe an extended order into the physician orders and MAR. The extension was based on a pharmacy recommendation signed by an NP, but the transcription error was acknowledged by the DON during a surveyor interview.
A resident on a pureed diet reported tasteless food due to the Dining Room Manager not following a recipe, using water instead of chicken broth, and omitting thickener, resulting in a lack of nutritive value and improper consistency. The Food Service Director admitted to not providing printed recipes, despite having access to them.
The facility did not have a current contract for dialysis services for a resident receiving hemodialysis. The DON could not provide the contract, and the NHA confirmed its absence, acknowledging that it should exist. The resident receives dialysis three times a week, but no explanation was given for the missing contract.
Failure to Provide Adequate Supervision and Safety Devices to Prevent Resident Falls
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including dementia, hypertension, and anxiety, was assessed as having severe cognitive impairment and was dependent on staff for several activities of daily living. The resident had a history of falls and was identified as being at risk for further falls, with a care plan in place that included specific interventions such as the use of Dycem on the wheelchair cushion to prevent slipping. Despite these interventions being documented in the care plan and Kardex, observations on multiple occasions revealed that Dycem was not present on the resident's wheelchair cushion as required. Staff interviews confirmed a lack of awareness regarding the presence of Dycem, and direct observation by the surveyor on two separate days confirmed its absence. The resident was observed propelling herself in the wheelchair and participating in daily activities without the prescribed safety device in place. Additionally, after the resident experienced a fall, the facility did not conduct a thorough investigation. The incident report lacked staff statements, did not identify a root cause, and did not provide evidence that prior interventions were in place to prevent the fall. The investigation was incomplete, and there was no documentation explaining why the Dycem was not in use according to the care plan at the time of the fall.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for a resident who was severely cognitively impaired. The resident was found with a new bruise on the left forearm, which was first noticed by a CNA. The resident was unable to clearly recall how the bruise occurred, providing inconsistent explanations, and staff interviews did not reveal any clear cause. The CNA who discovered the bruise promptly notified a nurse, and the incident was assessed and documented, with the resident’s Power of Attorney and physician being notified. According to facility policy, any incident or allegation considered reportable must be initially reported to the State Agency immediately or within 24 hours, with a follow-up investigation submitted within five working days. In this case, the Nursing Home Administrator (NHA) was made aware of the bruise and conducted interviews with the resident and staff, as well as a review of the resident’s environment. The NHA determined that no abuse had occurred and that the injury was likely accidental, possibly related to a malfunctioning dresser drawer or contact with a transfer device. However, the NHA encountered technical difficulties with the reporting system, including an expired account and issues submitting the required documentation. Despite attempts to notify the State Agency via email and eventually submitting the final investigation report, the required five-day follow-up report was not submitted within the mandated timeframe. The NHA acknowledged the delay and was unable to provide evidence of timely submission. The surveyor confirmed that the final investigative findings were not reported to the State Agency within the required five working days, constituting a deficiency in the facility’s abuse, neglect, and incident reporting procedures.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of an injury of unknown origin for one resident. A bruise was discovered on the resident's left forearm, and initial interviews were conducted with the Certified Nursing Assistant (CNA) who found the bruise and the Registered Nurse (RN) who assessed it. The resident, who is severely cognitively impaired, provided inconsistent accounts of how the bruise occurred, at times referencing bumping into a transfer device or a dresser drawer, but was unable to recall specific details. The facility's investigation included interviews with the resident, CNA, and RN, as well as interviews with other residents on the unit. However, the facility did not interview or obtain statements from all staff members who had worked with the resident during the shifts prior to the discovery of the bruise. Staff schedules indicated that additional CNAs were present during the relevant timeframe, but their input was not sought as part of the investigation. The facility's self-report and documentation did not reflect a review of staff schedules or comprehensive staff interviews to determine if any staff had observed the bruise earlier, witnessed the incident, or had information about transfers involving the resident. The facility's policy requires that all injuries of unknown origin be immediately and thoroughly investigated to rule out abuse. Despite this, the investigation was limited in scope and did not include all potentially relevant staff. The deficiency was identified when the surveyor noted the lack of comprehensive staff interviews and the absence of a full review of staff schedules in the facility's investigative process.
Failure to Involve Activated HCPOA in Care Planning
Penalty
Summary
A resident with diagnoses of dementia with anxiety, mood disturbance, and edema was admitted to the facility and had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment and inability to make daily decisions. The resident had an activated Healthcare Power of Attorney (HCPOA) responsible for participating in care planning. Despite this, the facility did not formally invite the HCPOA to participate in the resident's quarterly care conferences, as confirmed by both grievance logs and interviews with the HCPOA. Documentation for care conferences on two separate dates showed no evidence that the HCPOA was invited or participated. The surveyor reviewed multiple grievances from the HCPOA regarding lack of notification and participation in care conferences. Interviews with facility staff confirmed that the expectation was to include activated HCPOAs in quarterly care conferences, but this was not done for the resident in question. The administrator and DON were made aware of the concern, and no additional information was provided to indicate that the HCPOA was given the opportunity to be involved in the resident's care planning process.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted into an allegation of neglect involving a resident and a Certified Nursing Assistant (CNA). A self-report was submitted to the State Agency documenting allegations that a resident was neglected by the CNA. While the facility submitted the required reports to the State Agency within the appropriate timeframes, the internal investigation did not include interviews with all residents who may have had contact with the CNA on the South unit. The investigation was limited to interviews with only 12 out of 16 residents on the unit, and there was no documentation showing attempts to interview the remaining residents. The staff member responsible for the investigation stated they were unaware that all potentially affected residents should have been interviewed, believing that only a sample was necessary. The facility was unable to provide additional information or documentation to demonstrate that a comprehensive investigation had been completed.
Failure to Develop Care Plans for Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing refusal of care for two residents. One resident, admitted with a history of myocardial infarction and a sacral pressure injury, repeatedly refused evaluation and repositioning for a hospital-acquired coccyx pressure injury. Progress notes documented these refusals and the resident was educated on the risks and benefits, eventually agreeing to reposition every four hours. Despite these ongoing refusals and the resident's history of declining care, no care plan addressing refusal of care was developed during the resident's stay. Interviews with facility staff, including the wound nurse and DON, confirmed that a care plan for refusal of care should have been in place but was not. Another resident, admitted with dementia and chronic pain, had physician orders for heel boots to prevent pressure injuries. This resident was observed without heel boots on multiple occasions and had a documented stage 2 pressure injury. The resident frequently refused to wear the heel boots, as noted by both staff interviews and the treatment administration record, which showed at least 12 refusals over a period of several months. Despite this pattern of refusal, the resident's care plan did not address refusal of care. The DON confirmed that a care plan for refusal of care was required but had not been developed for this resident.
Sanitation and Infection Control Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner, affecting all three kitchens and potentially impacting all 39 residents. In the main preparation kitchen, air vents over the sink and near the dishwasher were found to be contaminated with dark brown spots, and the cleaning schedule was not adhered to, with the last cleaning occurring over seven months prior. Additionally, food items in the refrigerators were not properly dated or sealed, leaving them open to contamination, contrary to the facility's policy. In the Rehab/West Unit, the commercial dishwashing machine was non-operational, leading staff to use a residential dishwashing machine without proper sanitization or temperature logs. This practice was against the facility's guidelines, which required dishes to be washed in the main or Long Term Care kitchen. The lack of an approved dishwashing machine and the improper use of a residential machine posed a risk of inadequate sanitization of dishware. In the Long Term Care Unit kitchen, staff failed to follow infection control practices. Dietary staff handled clean dishware without gloves or proper hand hygiene, and a CNA was observed in the kitchen without a hair restraint, despite facility policy requiring hairnets. These lapses in infection control practices were observed and reported to the Nursing Home Administrator, who acknowledged the issues but did not provide further information.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's resuscitation code status was accurately reflected in their electronic health record (EHR) for the first 19 days of their stay. The resident, who was cognitively intact and had signed a Do Not Resuscitate (DNR) order on admission, was incorrectly documented as a full code in the EHR. This discrepancy was not identified until a surveyor's investigation revealed that the resident's DNR status was not transcribed into the EHR, despite being signed and filed in the paper chart. Staff interviews indicated a lack of clarity and consistency in the process for documenting code status. Certified Nursing Assistants and Licensed Practical Nurses relied on different sources, such as bracelets and Medication Administration Records, to determine code status, leading to confusion. The Director of Nursing acknowledged the discrepancy but could not explain why the signed DNR form was not scanned into the EHR. The issue was only discovered during a surveyor's review, highlighting a gap in the facility's procedures for ensuring accurate documentation of residents' code status.
Failure to Transcribe Physician Orders Correctly
Penalty
Summary
The facility failed to ensure that a resident's physician orders were transcribed correctly, resulting in a deficiency. A resident, identified as R24, was admitted with diagnoses including COPD, sleep apnea, and panic disorder. The resident had a physician order dated February 5, 2024, for clonazepam 0.5 mg to be administered twice daily as needed for anxiety, limited to 14 days. However, by July 23, 2024, the resident continued to receive this medication despite the original order's expiration. During an interview, the Director of Nursing (DON) acknowledged that the order was extended for another six months based on a pharmacy recommendation signed by a nurse practitioner on March 8, 2024, but this extension was not transcribed into the physician orders or the medication administration record (MAR). The facility did not provide additional information on why the transcription error occurred.
Failure to Follow Recipe for Pureed Diet
Penalty
Summary
The facility failed to ensure that food was prepared to conserve nutritive value and flavor for a resident on a pureed diet. The Dining Room Manager (DM-D) did not follow a recipe when preparing pureed food, instead relying on personal experience to determine the correct texture and consistency. During the preparation of a pureed chicken dish, DM-D used an unmeasured amount of hot water instead of chicken broth, which did not conserve the nutritive value of the food. Additionally, DM-D did not use thickener, resulting in a mixture that was not of a smooth, pudding-like consistency as required. The resident, who is cognitively intact and has diagnoses including chronic heart failure, protein-calorie malnutrition, and colon cancer, reported that the food lacked flavor. The Food Service Director (FSD-C) acknowledged the absence of printed recipes for pureed food, despite having access to a computer program with the necessary recipes. The Dietician (D-H) confirmed that recipes should be used for residents on pureed diets and provided the correct recipe for pureed baked chicken breast, which included specific measurements for chicken broth and thickener. The deficiency was communicated to the Nursing Home Administrator and Director of Nursing during the daily exit meeting.
Lack of Dialysis Service Contract
Penalty
Summary
The facility failed to secure a current contract or agreement for outside dialysis services for a resident receiving hemodialysis. During a survey, the Director of Nursing (DON) was unable to provide a dialysis contract for the company used by the resident, identified as R19, who receives dialysis three times a week. The Nursing Home Administrator (NHA) confirmed the absence of a contract and acknowledged that one should be in place. Despite requests for additional information, no explanation was provided for the lack of a dialysis contract for the resident's provider.
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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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Nursing homes near Mukwonago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Troy Manor | 4.3 mi | — | 5 | 0 |
| Masonic Center For Health & Rehab Inc | 11.6 mi | — | 1 | 0 |
| Lakeland Health Care Ctr | 13 mi | — | 5 | 0 |
| Holton Manor | 13.2 mi | — | 0 | 0 |
| Complete Care At Kensington | 13.6 mi | — | 1 | 0 |
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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.