Lindengrove Waukesha

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure resident representatives and three of three residents (Resident (R) 1, R9, and R10) reviewed for transfer requirements out of a sample of 10 were provided with written notification of the facility's bed hold policy prior to transfer to the hospital. The facility also failed to submit documentation of the facility discharge notices to representatives of the Office of the State Long-Term Care Ombudsman. By not ensuring information regarding the bed hold process is explained to residents and/or representatives could create distress or confusion related to readmission to the facility due to the facility-initiated discharge.

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

Inspectors wroteBased on interview and record review the facility did not ensure 6 (R3, R4, R1, R8, R19, and R47) of 6 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman, were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed. *R3 was transferred to the hospital on 4/3/25 and 5/20/25. A transfer notice and bed hold rate was not provided in writing to R3 and/or R3's representative. *R4 was transferred to the hospital on 7/16/25 and 8/11/25. A transfer notice and bed hold rate was not provided in writing to R4 and/ or R4's representative. *R1 was transferred to the hospital on 3/15/25. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all facility staff received required effective communication program training for 1 of 5 sampled Certified Nursing Assistants (CNAs). This deficient practice has the potential to affect residents who reside at the facility on the wing where CNA-W is working and have the potential to receive care from CNA-W. Findings Include:On 09/25/24, at 11:00 AM, Surveyor reviewed CNA-W's completed trainings for the past year and noted there was no documentation that CNA-W received training on the facility's effective communication program which outlined and informed staff of the elements and goals of the facility's effective communication program. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all facility staff received required Quality Assessment and Performance Improvement (QAPI) program training for 1 of 5 sampled Certified Nursing Assistants (CNAs). This deficient practice has the potential to affect residents who reside at the facility on the wing where CNA-W is working and have the potential to receive care from CNA-W. Findings Include:On 09/25/24, at 11:00 AM, Surveyor reviewed CNA-W's completed trainings for the past year and noted there was no documentation that CNA-W received training on the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all facility staff received required compliance and ethics program training for 1 of 5 sampled Certified Nursing Assistants (CNAs). This deficient practice has the potential to affect residents who reside at the facility on the wing where CNA-W is working and have the potential to receive care from CNA-W. Findings Include:On 09/25/24, at 11:00 AM, Surveyor reviewed CNA-W's completed trainings for the past year and noted there was no documentation that CNA-W received training of the facility's compliance and ethics program. On 9/25/24, at 12:01 PM, Surveyor requested missing documentation from NHA (Nursing Home Administrator)-A for CNA-W's training of the facility's compliance and ethics program. Surveyor was informed by NHA-A to call Learning Facilitator (LF)-X. [...]

Inspectors wroteBased on record review, staff and family interviews, the facility did not inform the resident or the resident's guardian of a psychoactive medication that required informed consent for administration for 1(R43) of 5 sampled residents reviewed for unnecessary medications. R43 received the antipsychotic medication Seroquel and the antidepressant medication Zoloft without receiving consent from R43's guardian.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R8 and R30) of 2 residents with allegations of abuse was reported to the State Survey Agency within the required reporting timeframe. *On 7/3/25, R8's Activated Power of Attorney (APOA) notified Director of Nursing (DON)-B that R8's wallet was missing. The facility started an investigated on 7/3/25 and submitted an initial report to the State Agency on 7/3/25, at 3:57 PM. The facility did not submit a 5-day report to the State Agency as required. *R30 informed Surveyor that a facility staff member, Certified Nursing Assistant (CNA)-F, yelled at R30 and made R30 scared. R30 had informed Certified Nursing Assistant (CNA)-E of the interaction between R30 and CNA-F. R30 stated that CNA-E informed R30 that CNA-E would file a complaint. [...]

Inspectors wroteBased on observation and staff interview the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (R2 and R13) of 15 residents reviewed R2 and R13 did not have comprehensive behavior care plans based on their comprehensive assessments for behavior management including targeted behaviors and non-pharmalogical approaches for behavior management.

Inspectors wroteBased on interviews and record review, the facility did not complete neurological checks in accordance with facility protocol and standards of practice for 2 (R2 and R13) of 4 residents reviewed for unwitnessed falls.*R2 sustained unwitnessed falls on 1/31/25, 2/2/25, 2/3/25, 5/16/25 and 7/1/25. Facility staff did not document neurological checks as completed per the facility protocol and standards of practice.*R13 sustained unwitnessed falls on 9/2/25 and 9/7/25. Facility staff did not document that neurological checks were completed per the facility protocol and standards of practice.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility must ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 1 of 6 (R50) residents reviewed for pressure injuries. R50's pressure injury was not comprehensively assessed upon admission. The pressure injury was assessed by the wound physician 6 days later and documented as an unstageable DTI (Deep Tissue Injury) with moderate serosanguinous exudate.

Inspectors wroteBased on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 3 (R1, R2, R43) of 5 residents reviewed. *R1 had pharmacist reviews dated 7/3/25, 8/7/25, and 9/3/25 with recommendations for a tardive dyskinesia assessment to be completed as R1 is on antipsychotic medication. The pharmacy recommendations were not followed up on. *R2's pharmacy reviews for 6/25, 7/25, 8/25, and 9/25 indicated that a screening for tardive dyskinesia assessment was needed to be completed due to Seroquel administration. The pharmacy recommendations were not followed up on. *The Pharmacist monthly review for R43 recommended the facility conduct an AIMS Assessment. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure its medication error rate is not 5 percent or greater. The medication error rate was 11.54%.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure hospice collaboration and communication was established to ensure continuity of care between hospice provider and the facility for 1 (R13) of 2 residents reviewed for hospice services. *R13 started receiving hospice care and treatment on 7/29/25. R13's hospice plan of care initiated on 7/29/25, included Lorazepam (an anti-anxiety medication) and Hydromorphone (a narcotic pain medication) to be ordered and implemented by facility staff. Facility staff did not enter the physician order for Lorazepam until 9/6/25 and Hydromorphone until 9/15/25. R13 sustained falls on 8/2/25, 8/9/25, 8/18/25 and 9/2/25. Facility staff did not inform hospice staff of these falls on the day the falls happened. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to accurately transcribe medication orders to ensure correct administration of prednisone (oral steroid) and failed to notify the provider of elevated blood glucose levels for one of three residents (Resident (R) 2) reviewed for blood sugars out of 10 sampled residents. This failure had the potential to result in withdrawal symptoms from not tapering the prednisone and in adverse health effects from not managing elevated blood glucose levels.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain wound treatment orders timely when a pressure injury was identified for two of three residents (Resident (R) 4 and R1) reviewed for pressure injury out of 10 sample residents. This had the potential for residents' pressure injuries to decline.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have medications available to administer as ordered for two of four residents (Resident (R) 9 and R2) reviewed for medication availability out of 10 sample residents. This had the potential to result in adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents with a pressure injury or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R8) of 3 residents reviewed for pressure injuries. R8 admitted to the facility with pressure injuries (PIs) on her left heel and right lateral foot which later resolved. R8 was assessed as high risk for PIs. Despite being at high risk, R8's physician's order for an air mattress was not implemented, a care plan for actual skin impairment was not initiated timely, and her weekly skin assessments were not completed weekly as per facility policy. [...]

Inspectors wroteBased on observation, interview and record review the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety in the kitchen and 1 of 2 serving areas with the potential to affect 44 residents. * Garbage cans in the kitchen were observed to be very soiled and a lid was not on a garbage can next to a food preparation area. * Multiple items in the kitchen were found to be undated and several were uncovered. * The handwashing sink in the kitchen was very dirty. * The serving area on the second floor was found to have a mop and bucket with dirty water next to a cart for food trays. * Several food storage bins were observed to have the scoop stored inside the bin in direct contact with the product. Findings Include: On 5/28/24 at 8:48 AM the following was observed in the kitchen: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that residents have reasonable access to the use of telephone, in a place where calls can be made without being overheard. The facility provided telephones in resident's rooms on the first floor while resident's living on the second floor of the facility did not have reasonable access to the use of telephone. This deficient practice has the potential to affect 28 of 28 residents residing on the second floor of the facility who could request the use of telephone.

Inspectors wroteBased on interview and record review, the facility did not ensure information was provided and consent was obtained for a resident who was prescribed psychotropic medications for 1 (R37) of 5 residents reviewed for unnecessary medications. R37 was prescribed Mirtazapine and Trazadone which are antidepressant medications. The facility did not obtain written consent from R37's Power of Attorney (POA) for these medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R34) of 5 Residents observed for medication pass. R34 did not have a self-administration of medication assessment or a physician's order to self-administer medication.

Inspectors wroteBased on interview and record review the Facility did not notify a resident's representative or attending physician when there was a change of condition involving 1 (R45) of 14 residents in the sample. R45 had a fall with injury and was transported to the hospital. There was no documentation R45's representative or attending physician were updated when the change of condition occurred.

Inspectors wroteBased on interview and record review, the facility did not ensure a safe, home-like environment that provided reasonable care for the protection of a resident's property from loss for 1 (R33) of 1 residents reviewed. Two of R33's shirts were lost after R33 sent them to be cleaned by the facilities laundry department. R33 informed the facility. The facility started the process of locating the missing the shirts but did not follow through with locating them in a timely manner.

Inspectors wroteBased on interview and record review, the facility did not ensure information from the baseline care plan was reviewed with resident and a copy or summary of the plan was provided to the resident for one (R10) of one residents reviewed.

Inspectors wroteBased on observation and staff interview the facility did not develop and implement a comprehensive person-centered care plan for 1 (R100) of 12 residents to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary ADL (Activity of Daily Living) services for 2 (R8 and R31) of 14 residents that were dependent on staff to assist with ADL care. * R8 was observed to have long, dirty fingernails on both hands and was itching an open wound. * R31 was observed to have right and left hand contractures, R31's nails on both hands were long and dirty and had the potential of cutting into R31's palms.

Inspectors wroteBased on interview and record review, the facility did not provide an ongoing, individualized and meaningful activities program designed to meet the residents interest and support their physical, mental and psychosocial well-being for 2 (R247 and R33) of 2 residents reviewed for activities. R247 and R33 reported that they would like to participate in organized group activities on the weekend but activities are not offered on the weekends.

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 (R6) of 3 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. * R6 did not have a falls care plan initiated until 12/4/2023 even though R6 was admitted to the facility because of a fall at R6's previous residence and assessed at a high risk for falls.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R31) of 2 reviewed for an indwelling catheter had a valid medical justification for continued use of the indwelling catheter, received necessary services for monitoring of the indwelling catheter and provide dignity for resident who had an indwelling catheter. R31 was admitted to the facility with a foley catheter. There was no diagnosis or justification for the catheter, no size indicated, and no orders for monitoring or cares for the indwelling catheter. Observations were made of catheter bag not being in a privacy bag.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the necessary care and services to provide respiratory care were consistent with professional standards of practice for 1 (R31) of 1 resident reviewed for respiratory care. R31's oxygen tubing was not labeled, there was no care plan for respiratory/ oxygen use, and no orders in place for care of oxygen supplies.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 (R7 and R34) of 5 Residents observed for medication pass. R7 and R34 were not provided medications that were on the physician orders due to not having on medication cart yet were signed out as given on the Medication Administration Record (MAR).

Inspectors wrote2.) R6 was admitted to the facility on [DATE] and has diagnoses that include age-related osteoporosis, neuropathy, low back pain, spinal stenosis- cervical region and lumbar region, glaucoma, bradycardia, and abnormalities of gait and mobility. R6's quarterly minimum data set (MDS) dated [DATE] indicated R6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15, PHQ-9 (patient health questionnaire-9- screening/diagnosing/monitoring/and measuring the severity of depression) score of 0 indicating no depressive symptoms, and R6 did not have any behaviors. Surveyor reviewed R6's medical record and noted an order for: 1. Duloxetine HCl oral capsule, Delayed release particles 40 MG (Duloxetine HCl)- Give 40 mg by mouth in the morning for depression (Start: 3/27/2024) 2. Anti-depressant medication use- observe resident closely for significant side effects: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 3 residents (R7, R35 and R100) of 5 residents observed receiving medications. The facility medication error rate was 11.11%. *R7 did not have Voltaren Gel applied per order and the gel was signed out on the Medication Administration Record (MAR). *R34 did not receive Hydrochlorothiazide 12.5 mg tablet which was signed out on the MAR. *R100 did not receive Amlodipine 10mg tablet which was signed out on the MAR.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 3 residents reviewed (R100) was free of significant medication errors. * R100 had an order for Vancomycin every 3 days transcribed twice so she received double the ordered dose from 4/12/24 to 5/28/24 when it was brought to the facility's attention.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from medication carts. This occurred for 3 of 5 medication carts/storage rooms observed. The refrigerators in the 1st and 2nd floor medication storage rooms did not have monitoring of temperatures recorded R9's Insulin Glargine was stored in the medication cart beyond use by date

Inspectors wroteBased on observation, interview, and record review the facility did not ensure they posted the nurse staffing data to include the date, resident census, and the total actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurses Aides, on a daily basis. This has the capability to affect all 44 residents which is the total census upon survey entrance.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (Resident (R)8) of 11 residents reviewed for code status was accurately documented throughout the medical record. This had the potential for the resident and/or responsible party's wishes not to be honored.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure that a resident who was admitted without a pressure injury was properly assessed and monitored to prevent the development of a pressure injury for one resident (Resident (R) 5) out of three residents reviewed for pressure injuries. This resulted in the development of a facility acquired, stage 3 pressure injury.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete a thorough investigation of a fall for one (Resident (R) 5) of three sampled residents reviewed for falls. This had the potential for additional falls and potential injuries to the resident.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to provide incontinence care in a timely manner for one of three sampled residents (Resident (R) 3) reviewed for incontinence care. The failure of the facility to check and change the resident after an incontinent episode put the resident at risk for developing skin issues and potentially an urinary tract infection (UTI).

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy, the facility failed to ensure staff performed hand hygiene during incontinence care for one resident (Resident (R) 3) of one observed during from a sample of 11 residents. This had the potential for infection control not being maintained.

Inspectors wroteBased on observation and interview, the facility did not ensure staff followed transmission- based precautions for 1 (R2) of 1 residents who tested positive for SARS-CoV-2. This practice has the possibility to affect 19 residents residing on in the facility. Surveyor observed CNA (Certified Nursing Assistant) G assist a SARS-CoV-2 positive resident (R2) in their room without donning an N95 mask.

Inspectors wroteBased on interview and record review the facility did not immediately inform the resident's physician and Power of Attorney for Healthcare (POAH) of a significant change in the resident's status for 1 (R4) of 8 residents reviewed for a change in condition notification. * R4 had a documented 17 pound weight gain in 7 days which could indicate an underlying health concern and R4's physician and his POAH were not notified.

Inspectors wroteBased on interview and record review, the Facility did not ensure that a comprehensive care plan was developed for 1 (R12) of 8 Residents. R12 did not have problem areas of psychotropic medication and nutritional status identified on R12's care plans.

Inspectors wroteBased on record review and interview the facility did not ensure 2 (R4, R12) of 2 Residents with significant weight changes received the necessary care and treatment. * On 1/30/23 R4 weighed 166 pounds and on 2/6/23 R4 weighed 183 (a 17 pound weight gain in 7 days) no intervention was taken by the facility after the weight gain. R4 was not weighed per the facility policy which indicated R4 should have been weighed on admission and every week for 4 weeks. R4's admission assessment did not include a weight and the section was left blank. *On 1/9/23, R12 weighed 177.4 pounds and on 1/16/23, R12 weighed 147.2 pounds (a 30.2 pound weight loss in 7 days); no intervention was taken by the facility after the weight loss.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure psychotropic medications were adequately monitored for indications for use. This was observed with 1 (R12) of 2 residents reviewed on psychotropic medications. R12 was admitted to the facility on antipsychotic and antidepressant medication without behavioral indications for use nor behavioral monitoring.