Lindengrove Mukwonago

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

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

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 resident was clinically appropriate to self-administer medications. R1 was observed with a white pill on R1's breakfast tray and approximately four pills in a medication cup on R1's breakfast tray located on the over bed table next to R1. R1 does not have a self-administration assessment.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R2) of 16 residents reviewed for advanced directives had wishes clearly documented in the medical record. R2 did not have a current physician's order clarifying code status and R2's electronic medical record did not specify code status.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with a pressure injury, or those at risk for pressure injuries, received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 2 (R8, R21) of 4 residents reviewed for pressure injuries from a sample of 12. *R8 developed a pressure injury to the right inner ankle on 1/31/25, which progressed to a stage 3 pressure injury and became infected on 11/19/25 resulting in R8 having pain at the wound and requiring 2 antibiotics to treat the infection. R8 was assessed to be a high risk for developing pressure injuries. R8's care plan was not revised with alternative interventions when R8's right inner ankle wound progressed to an unstageable pressure injury. [...]

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure 1 (R40) of 2 residents received adequate supervision and assistance devices to prevent accidents.* R40's fall on 11/16/25 was not thoroughly investigated and a root cause was not determined to help prevent further falls. On 12/9/25 & 12/10/25, Dycem was not observed on R40's wheelchair per R40's falls plan of care.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 (R54, R3) of 2 received urinary catheter care in accordance with standards of practice. *R54's foley catheter bag was observed directly on the floor without a protective barrier. R54's foley catheter order did not specify the proper size of catheter or the proper balloon inflation size. *R3's foley catheter order did not specify the proper size of catheter or the proper balloon inflation size.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 of 2 (R54, R1) received respiratory treatment in accordance with standards of practice. *R54's Continuous Positive Air Pressure (CPAP) device did not have physician's orders in place regarding proper settings or maintenance of their CPAP device. *R1 did not receive oxygen therapy in accordance with their physician's orders.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R1) of 1 resident have consistent pre & post dialysis communication and are monitored for complications for residents whom receive dialysis treatments.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R1) of 1 residents with an injury of unknown origin was reported to the State Survey Agency withing the required reporting timeframe. R1's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on [DATE]. Nursing Home Administrator (NHA)-A stated in an interview that the Misconduct Incident Report was submitted to the State Survey Agency on [DATE], which is past the 5-business day required timeframe.

Inspectors wroteBased on interviews and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 (R1) of 1 residents reviewed. Facility staff found a bruise on R1's left forearm on 4/13/25. Certified Nursing Assistant (CNA)-C informed Surveyor that R1 told CNA-C that the bruise happened the night before. R1 told Registered Nurse (RN)-D that R1 bumped R1's arm on the sit-to-stand transfer device. The facility investigation into R1's bruise included 2 staff interviews from CNA-C and RN-D. The facility did not interview or get statements from other staff members that had worked with R1 in the previous shifts before the bruise was found.

Inspectors wroteBased on interview and record review the facility did not provide the opportunity for 1 (R1) of 4 residents reviewed to participate in the development and implementation of their person-centered plan of care. *R1's Activated Healthcare Power of Attorney (HCPOA) was not formally invited by the facility to participate in R1's Quarterly care conferences Findings Include: 1.) R1 was admitted to the facility on [DATE] with diagnoses of Dementia with anxiety, Mood disturbance and Edema. R1's Quarterly Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score to be a 00, indicating R1 is severely cognitively impaired and unable to conduct daily decision making. R1 has an activated HCPOA. On 3/19/25 at 10:15 AM, Surveyor reviewed the grievance log and noted there were multiple grievance from regarding R1. Surveyor requested copies of grievances. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations involving potential neglect were thoroughly investigated for 1 of 1 self-reports reviewed. * A Facility Misconduct Incident self-report submitted to the State Agency on 3/18/25 documents allegations that R4 was neglected by Certified Nursing Assistant (CNA)-F. The facility did not conduct a thorough investigation into this allegation of neglect when the facility's investigation did not include all interviews from other Residents in order to determine a possible pattern of neglect. Findings Include: Surveyor noted the facility had properly completed the following related to R4's allegation of neglect: -Submitted the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report within the required reporting time to the State Agency. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not develop and implement a comprehensive person-centered care plan for 2 (R2 and R3) of 4 residents to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. * R2 and R3 frequently refused care and treatment and no care plan for refusal of care was developed.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect 3 of 3 kitchens serving food and 39 of 39 residents residing in the facility. * Vents over the sink and near the dishwasher in the main preparation kitchen were contaminated with dark brown spots on the surface. * Food in the 2 refrigerators in the main preparation kitchen was stored without an open on date and liquid egg cartons were not sealed. * The Rehab/West Unit did not have an approved dish washing machine. There were 2 kitchen staff utilizing this dish washing machine. * The Main/Long Term Care Unit kitchen was observed with staff not utilizing preventative infection control practices.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's record reflected the accurate resuscitation code status election for 1 (R13) of 12 residents reviewed for code status. *R13's Emergency Care Do Not Resuscitate Order (DNR) form was signed by R13 and R13's Physician on 7/3/2024. R13's physician orders from 7/3/2024-7/22/2024 documents R13 is a full code. R13's code status in the Electronic Health Record (EHR) did not match R13's wishes for the first 19 days of R13's stay in the facility.

Inspectors wroteBased on interview and record review the facility did not ensure 1(R24) of 5 residents had physician orders transcribed correctly. R24 had a physician order dated 2/5/24 for clonazepam 0.5 mg twice daily as needed for anxiety X 14 days. On 7/23/24, R24 continued to have this order and was receiving this medication despite the original order indicating it was only for 14 days.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 1 (R11) of 1 residents on pureed diet. R11 informed Surveyor that R11's food lacked flavor. The Dining Room Manager (DM-D) did not follow a recipe for preparing texture and modified consistency diet for pureed food.

Inspectors wroteBased on record review and interview the facility did not acquire a current contract /agreement in writing for outside dialysis services for 1(R19) of 1 residents receiving hemodialysis.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to report allegations of abuse and neglect to the State agency immediately and failed to report the results of the investigation within five working days of the incident. This involved three (Resident (R) 1 R2, and R3) of three allegations of abuse/neglect investigation reports reviewed.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure allegations of abuse and/or neglect were thoroughly investigated in a timely manner, failed to prevent potential further abuse, and failed to report allegations of abuse and neglect to the Administrator and the State agency immediately. This involved three (Resident (R) 1 R2, and R3) of three allegations of abuse/neglect investigation reports reviewed.

Inspectors wroteBased on record review and interview the Facility did not revise 1 (R22) of 12 Resident's care plans. * R22 had a fall on 3/16/23. R22's care plan was not revised with new interventions to try to prevent future falls.

Inspectors wroteBased on observation, interview and record review the facility did not ensure the prevention of pressure injury development for 1 (R1) of 1 residents reviewed for pressure injuries. R1 developed 3 facility acquired pressure injuries (coccyx, right heel and right lateral ankle) and the care plan did not identify risk factors to prevent the development of pressure injuries (an immobilizer for the right leg post surgery) from occurring nor revision of the care plan after pressure injuries were found.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R22) of 7 residents received the necessary services to prevent falls. * R22 had a fall on 3/16/22 without injury. The facility did not meet with the interdisciplinary team (IDT) to discuss the fall and develop new interventions to prevent future falls.

Inspectors wroteBased on observation, interview and record the facility did not ensure 1 (R77) of 1 resident on fluid restriction received the necessary services to monitor their fluid intake. R77 had an order on 3/28/23 to monitor the fluid intake due to being on an 1800 cc (cubic centimeter) fluid restriction. The facility were not consistently monitoring her daily fluid intake.