Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lindengrove New Berlin during CMS and state inspections, most recent first.
A resident who was dependent on staff for eating, had dysphagia, and required a mechanically altered diet was left with a meal tray without direct supervision while a CNA left the dining room to deliver room trays. The resident choked on bread, required the Heimlich maneuver, was later diagnosed with aspiration pneumonia, and died with aspiration pneumonia listed as the immediate cause of death. The report also cited multiple fall-related failures, including an uninvestigated fall, missing fall interventions, and inadequate root-cause review of repeated falls.
A resident with stroke-related dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet by the hospital, but the facility used a mechanical soft diet that included bread. The ST could not recall assessing the resident’s ability to eat bread, and the resident was served a tuna sandwich. During the meal, staff found the resident choking and removed a large piece of bread from the mouth. The resident was later hospitalized with aspiration pneumonia and respiratory failure and died; the death certificate listed aspiration pneumonia as the immediate cause of death.
Grievances were not properly investigated or resolved for two residents. One resident’s family complained about long call light response times, but surveyors found no grievance documentation showing the concern was investigated or resolved, despite multiple call light waits over 10 minutes. Another resident’s family filed a grievance that the resident was not getting help to use the restroom, but the documented resolution only reminded the resident to use the call light and did not address the actual concern. Staff interviews confirmed awareness of the call light issues and that grievance resolutions were discussed in weekly meetings, but the records did not show the root concerns were addressed.
Failure to Thoroughly Investigate Neglect Allegation: The facility did not thoroughly investigate a family allegation of neglect involving a resident who had recently returned from the hospital after CABG and aortic valve repair. Although staff and other residents were interviewed, the resident was not interviewed even though the record showed he was alert, able to make needs known, and had a BIMS score of 12 indicating moderate cognitive impairment; the facility’s policy required resident statements to be obtained when investigating abuse or neglect allegations.
A resident admitted with a Foley catheter and moderate cognitive impairment had the catheter discontinued, but the facility did not complete a comprehensive bladder assessment, document a voiding pattern, or develop a urinary incontinence care plan afterward. Although post-void residual checks were done and later urinary evaluations noted frequent incontinence and a history of UTI, key assessment items were left incomplete and the care area assessment lacked an analysis of the urinary problem.
Two residents with significant fall risk and cognitive impairment experienced multiple falls due to inadequate supervision and incomplete investigations. The facility did not consistently update care plans to address self-transferring behaviors or ensure that interventions were communicated to staff, resulting in repeated incidents and, in one case, a pelvic fracture.
A resident with significant neurological and physical impairments reported to their family that an aide intended to take a picture of their bowel movement. The family immediately notified the NHA by email, but the allegation was not reported to the state agency within the required timeframe because the NHA did not review the email until after a holiday. The facility lacked a process for monitoring and responding to time-sensitive allegations during weekends or holidays, resulting in delayed reporting.
A resident with multiple medical conditions developed a rash in skin folds, which was documented during a routine skin assessment. Despite facility policy requiring physician notification for changes in skin integrity, the physician was not informed, and staff could not provide a reason for this omission. Documentation showed the rash was treated with barrier cream, but no medical evaluation was sought.
A resident with cognitive impairment and physical disabilities suffered a head injury after slipping from a sit-to-stand lift during a transfer performed by only one CNA, despite the care plan requiring two staff. The CNA was unaware of the two-person requirement, and documentation regarding sling size and transfer procedures was lacking. The facility's investigation did not address whether proper procedures and equipment were used during the transfer.
A resident with significant cognitive and physical impairments was found with a large bruise and skin tears at the base of the neck, but the facility failed to thoroughly investigate the cause. Staff interviewed had not cared for the resident on the day of the injury, the injury was not properly measured or documented, and residents interviewed for safety concerns were from different units. The facility's report to authorities could not be verified, and the investigation did not follow established policy.
A resident with severe cognitive impairment and multiple medical conditions sustained a significant leg injury requiring surgery after hitting her shin on a sit-to-stand lift during a transfer. The facility failed to conduct a thorough investigation into the incident, and the resident was left alone on the toilet with the leg strap unfastened, contributing to the injury. The facility lacked a specific policy for the lift's use and did not provide adequate staff training, resulting in a deficiency in ensuring resident safety and supervision.
The facility was found to have deficiencies in the dishwashing process, potentially affecting all 87 residents. Dietary staff were observed handling dirty items and then clean items without proper hand hygiene or changing gloves, contrary to facility policy. The Kitchen Lead noted the staff were new and explained the sanitization process to them.
The facility failed to implement an effective infection prevention and control program, affecting residents, staff, and visitors. There was no documentation of investigations into infection outbreaks or a system to track staff illnesses. During a COVID-19 outbreak, the facility's line list was incomplete, and there was no investigation into the spread across units. Enhanced barrier precautions were not implemented for residents with wounds, and staff were unclear about the requirements. Additionally, the facility did not adequately track staff illnesses, contributing to ineffective infection management.
The facility failed to date opened insulin vials and pens, as observed in multiple medication carts and rooms. Insulin types such as Novolog, Lantus, and Lispro were found open and used without being dated, contrary to the facility's policy requiring the recording of the date opened and expiration. This deficiency was noted across various units and floors, highlighting a lapse in medication management protocols.
The facility failed to ensure safe and clinically appropriate self-administration of medications for three residents. One resident had medications at their bedside without an assessment or care plan, another self-administered medications left on their breakfast tray without proper documentation, and a third had unlabeled medications without physician orders or an assessment. These deficiencies highlight a lack of oversight and documentation in the facility's medication management process.
The facility failed to provide required written notifications of transfer, including appeal rights, to three residents transferred to the hospital due to changes in their conditions. The facility also did not notify the State Ombudsman as required. Interviews with staff revealed a lack of documentation and a systemic issue in the notification process.
The facility failed to provide written notice of the bed hold policy to three residents when they were transferred to the hospital. Despite the responsibility of floor nursing staff to issue these notices, they were not provided in these cases. One resident, with multiple medical conditions, was transferred due to severe symptoms, yet no bed hold notice was given. The facility's eInteract transfer form lacked the required regulatory information.
A facility failed to assess the necessity of a Foley catheter for a resident who was admitted without one and returned from hospitalization with it. The resident's medical records lacked documentation or a valid diagnosis justifying the catheter's use. Despite the absence of genitourinary issues in the hospital discharge summary, the facility did not evaluate the need for the catheter's removal, leading to a deficiency.
A resident with multiple diagnoses, including Alzheimer's and dementia, was unable to be transferred due to a shortage of appropriate slings for a Hoyer lift. Staff reported a longstanding issue with sling availability, requiring them to search different units or the laundry. Despite management's belief that slings were accessible, surveyors found none on linen carts, and staff confirmed the ongoing problem, affecting the accommodation of resident needs.
A resident admitted with surgical incision wounds did not receive appropriate care and monitoring in accordance with professional standards. The facility failed to document the incisions in the care plan, and no comprehensive assessments or orders were in place. Staff interviews revealed a lack of awareness and documentation regarding the resident's surgical wounds, leading to inadequate care during the resident's stay.
A resident with multiple health issues experienced two falls in one day due to inadequate supervision and failure to implement a fall mat as per the care plan. The facility's investigation lacked thoroughness, with missing staff statements and inconsistent documentation, contributing to repeated falls and injuries.
A resident admitted with a Foley catheter did not receive timely orders for catheter care and monitoring, as required by facility policy. Despite having multiple diagnoses, including a urinary tract infection, the necessary orders were delayed, and the facility did not provide a reason for this oversight. The unit manager and DON acknowledged that standing orders should have been implemented upon admission.
Failure to Provide Adequate Supervision During Meals and Manage Fall Risks
Penalty
Summary
The facility did not ensure adequate supervision and assistance to prevent accidents for a resident who was dependent on staff for eating, required a mechanically altered diet, and had dysphagia, vascular dementia, and a history of stroke-related hemiplegia. The resident’s care plan and speech therapy notes documented the need for supervision while eating, small bites, cueing to slow down, and assistance with feeding. Speech therapy also documented that the resident had oral residue, impulsive eating behavior, and signs and symptoms of aspiration during swallowing trials. On the day of the choking event, the resident was in the dining room when a CNA left to deliver room trays. The resident’s food tray was placed in front of the resident without staff supervision. Staff later observed the resident choking and initiated the Heimlich maneuver. A large piece of bread was expelled from the resident’s mouth, and EMS also documented a big piece of bread near the resident’s head. The resident was sent to the hospital and later diagnosed with aspiration pneumonia, and the death certificate listed aspiration pneumonia as the immediate cause of death. The report also identified deficiencies related to falls for multiple residents. One resident sustained a fall that resulted in a left femur fracture and hemiarthroplasty, then had another fall that was not investigated and had no updated fall interventions added to the care plan. Other residents had fall interventions that were not in place, falls that were not thoroughly investigated, a history of repeated falls related to alcohol intoxication that was not addressed as a root cause, and a fall with no prior interventions in place.
Failure to follow altered-texture diet standards led to choking event
Penalty
Summary
The facility did not ensure professional standards of practice were followed for a resident with dysphagia who was placed on an altered texture diet and later choked on bread. The resident had a history of stroke-related hemiplegia, dysphagia, moderate cognitive impairment, and dependence on staff for eating. The hospital SLP recommended an IDDSI Level 6 soft and bite-sized diet, which does not include regular dry bread, but the facility instead placed the resident on a mechanical soft diet and served foods that included bread. The record showed the facility did not follow the IDDSI standard of practice and did not document that the resident’s ability to eat bread was assessed. The facility ST stated they did not recall whether bread had been assessed, and the facility dietitian stated the facility did not currently follow IDDSI and instead used a company crosswalk that treated IDDSI Level 6 as comparable to mechanical soft. The facility’s mechanical soft menu included a tuna salad sandwich, and the resident’s meal ticket instructed mechanical soft with feeding assistance, small bites, and cueing. On the evening of the choking event, staff found the resident choking while eating. A CNA removed a very large piece of food from the resident’s mouth, described as a whole bun or a big piece of bread. An LPN and EMS also documented that a large piece of bread was present. The resident was hospitalized with aspiration pneumonia and acute respiratory failure, later developed worsening respiratory status, and died; the death certificate listed aspiration pneumonia as the immediate cause of death.
Grievances Not Investigated or Resolved Appropriately
Penalty
Summary
The facility failed to ensure grievances were investigated and resolved for 2 of 18 residents reviewed. One resident’s family complained about long call light response times, but there was no evidence that the facility investigated or resolved that grievance. Survey review of the resident’s call light log showed multiple response times over 10 minutes during the resident’s stay, including several entries lasting 11 to 30 minutes. Although facility staff acknowledged awareness of call light concerns and stated the issue would be reviewed by leadership, surveyors could not locate a grievance in the grievance binder for the call light complaint. For another resident, the facility documented a grievance filed by the family regarding the resident not getting help to use the restroom. The grievance form showed that staff reviewed the call light log and noted that call lights were not always answered within the expected timeframe, and the resident’s call light log contained numerous entries across several days. However, the documented resolution stated only that the resident was reminded to use the call light so staff could assist with ADLs. Survey review found that this resolution did not address the actual concern that the resident was not getting help to use the bathroom. The facility’s grievance policy stated that grievances would be forwarded to the designated grievance officer and investigated through the QAPI committee, and that the assigned manager would investigate and respond within five working days unless further investigation was needed. During interviews, the grievance officer stated grievances and their resolutions were discussed in weekly meetings, and staff acknowledged the call light response times were longer than the expected range. Despite this, the record did not show that the first resident’s family grievance was documented and resolved, and the second resident’s grievance resolution did not address the root concern raised by the family.
Failure to Thoroughly Investigate Neglect Allegation
Penalty
Summary
The facility did not ensure that 1 of 2 allegations was thoroughly investigated when R93’s family alleged neglect on 10/7/25. The facility’s investigation documented that the Nursing Home Administrator spoke with a family member who said they could not stay because of the “awful, neglectful care” the resident had received since moving into the building 4 days earlier, and that the concern was reported to DHS as an allegation of neglect. Survey review found multiple staff and three residents were interviewed, but R93 was not interviewed as part of the investigation. R93’s record showed he was admitted after hospitalization for elective CABG and aortic valve repair followed by an aortic valve leak. On 10/3/25, he was documented as alert and oriented times four, forgetful at times, able to make needs known, one assist with transfers, and occasionally incontinent of bladder. His 5-day MDS dated 10/9/25 showed a BIMS score of 12, indicating moderate cognitive impairment. The facility policy stated that abuse and neglect reports are to be promptly and thoroughly investigated and that resident statements should be obtained, including attempting to interview the resident first when possible.
Failure to Assess and Plan Care After Foley Removal
Penalty
Summary
The facility did not ensure appropriate treatment and services for a resident who was incontinent of bladder after an indwelling Foley catheter was discontinued. The resident was admitted with a Foley catheter for acute urinary retention and/or bladder outlet obstruction, had a BIMS score of 11 indicating moderate cognitive impairment, and was dependent for toileting hygiene and toilet transfer. The resident’s urinary continence evaluation and care area assessment documented the catheter and related urinary issues, but the care area assessment did not include an analysis of the nature of the problem/condition. After the Foley catheter was removed, the facility completed post-void residual checks every shift for three days, but the surveyor could not locate a voiding pattern, a comprehensive bladder assessment, or a urinary incontinence care plan following catheter removal. The resident’s later continence evaluation documented a history of urinary incontinence and UTI, frequent incontinence, and present perception of the need to void, but several assessment items related to voiding symptoms, post-voiding perception, type of incontinence, and appropriate interventions were not completed. Facility leadership told the surveyor they usually review CNA charting and update the care plan after catheter removal, but no such assessment or care plan was found for this resident.
Failure to Prevent Accidents Due to Inadequate Supervision and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, as required by policy. Both residents had a history of falls and were identified as being at risk, yet the facility did not conduct thorough investigations following multiple fall incidents. For one resident, repeated self-transferring behaviors were documented, but these were not addressed in the care plan, and interventions were not updated to reflect the ongoing risk. The facility's investigations into the falls did not consistently include key information such as who last observed the resident, what the resident was doing prior to the fall, when the resident was last toileted, or whether prior interventions were in place and effective at the time of the incident. In several instances, the facility's documentation and investigative process were incomplete. Staff statements were not always obtained or included in the investigation packets, and there was a lack of evidence that staff were interviewed regarding the circumstances of the falls. The care plans for the residents did not address self-transferring behaviors, despite staff being aware of these actions. Additionally, interventions such as offering toileting with every interaction were not consistently communicated to or implemented by direct care staff, as observed by the surveyor during interviews and record reviews. The residents involved had significant medical histories, including cognitive impairment, hemiplegia, diabetes, and chronic kidney disease, which increased their vulnerability to falls and injuries. Despite these risk factors, the facility did not ensure that all fall prevention interventions were in place or that staff were adequately informed of changes to care plans. The lack of thorough investigation and failure to address known risk behaviors contributed to repeated falls and, in one case, a pelvic fracture requiring hospitalization.
Failure to Timely Report Allegation of Mistreatment Due to Inadequate Weekend/Holiday Procedures
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or mistreatment in accordance with federal and state requirements. Specifically, an allegation of mistreatment and neglect was reported by a resident's daughter via email to the Nursing Home Administrator (NHA) on a Sunday evening. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours if not. However, the incident was not reported to the State Survey Agency until two days later, after the holiday weekend. The resident involved had significant medical conditions, including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, polyneuropathy, morbid obesity, and chronic pain syndrome. The resident was cognitively intact, able to communicate effectively, and had no documented behavioral or depressive symptoms. The concern arose when the resident informed their daughter that an aide had stated an intention to take a picture of the resident's bowel movement, prompting the daughter to immediately notify the NHA via email. Despite the facility's established policy, the NHA did not review the email until after the holiday, resulting in a delay in reporting the allegation to the state agency. The NHA confirmed that there was no process in place for monitoring time-sensitive emails over weekends or holidays, and no other staff were assigned to scan for such communications. The delay in reporting was attributed to the NHA being the sole recipient and reviewer of these communications, and the lack of an alternative process for timely response during periods when the NHA was unavailable.
Failure to Notify Physician of Resident's Rash
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including hemiplegia, polyneuropathy, morbid obesity, and chronic pain syndrome, developed a rash in the abdominal and breast folds. The facility's policy required that any changes in skin integrity be reported to the physician, and the resident's care plan included interventions to minimize skin breakdown, such as regular skin assessments and staff assistance with hygiene and repositioning. Despite these protocols, a skin assessment documented the presence of a rash, but there was no evidence that the physician was notified as required. The Skin Only Evaluation completed on the resident indicated a rash with moderate redness, but the section for provider notification was left blank, and no education was documented as provided. A late entry nurse's note, created several weeks after the initial finding, stated that the resident was cleaned and barrier cream was applied, but again, there was no indication that the physician was informed. Interviews with facility staff, including the Nurse Supervisor and DON, confirmed that the physician was not contacted regarding the rash, and staff were unable to provide a reason for this omission. The deficiency was further substantiated by the facility's own documentation and staff statements, which showed a lack of adherence to both the facility's skin care policy and professional standards of practice. The failure to notify the physician of the resident's rash meant that appropriate medical evaluation and treatment could not be initiated in a timely manner, as required by the resident's care plan and facility protocols.
Failure to Follow Care Plan and Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, dementia, paraplegia, and other significant medical conditions experienced a fall while being transferred using a sit-to-stand lift. The resident's care plan and CNA Kardex both specified that transfers required the use of a sit-to-stand lift with assistance from two staff members. However, on the evening of the incident, only one CNA was present during the transfer. The resident slipped out of the sling, fell, struck the back of her head, and briefly lost consciousness, resulting in a laceration that required two staples. The investigation revealed that the CNA performing the transfer was not aware that two staff were required for the procedure, despite this being documented in the care plan and Kardex. The CNA also did not recall if the transfer required one or two staff or what sling size was needed. Interviews with other staff indicated that sling sizes were not documented on the Kardex or care plan, and slings were not labeled for individual residents. There was also no evidence of recent training for staff on determining sling size, proper sling attachment, or safe transfer procedures prior to the incident. The facility's investigation into the incident did not address whether the correct sling size was used, if the sling was properly attached, or if the CNA had adequate knowledge of the transfer requirements. The root cause analysis focused on the resident's underlying diagnoses and loss of balance, but did not fully explore staff compliance with the care plan or equipment use. The surveyor noted that the care plan was not followed, as only one staff member assisted with the transfer, directly contributing to the resident's fall and injury.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse or neglect involving a resident who was found with a large bruise and skin tears at the base of the neck. The facility's investigation did not include interviews with staff members who had direct contact with the resident on the day the injury was discovered. Instead, statements were obtained from staff who were not assigned to the resident on that day and had no knowledge of the incident. Additionally, the investigation did not include a physical assessment or recreation of the transfer process to determine if the injury could have been caused by the mechanical lift, as was suggested by facility administration. The documentation of the injury was inconsistent, with conflicting dates reported for when the injury was discovered and discrepancies in the number of open areas within the bruise. The bruise itself was not measured or thoroughly described in the medical records. Furthermore, the residents interviewed to assess safety concerns were from different units and floors, and therefore did not interact with the same staff as the injured resident, limiting the effectiveness of the investigation in ruling out potential abuse by staff members involved in the resident's care. The resident involved had significant medical needs, including hemiplegia, moderate cognitive impairment, and was dependent on staff for all activities of daily living, requiring the use of a full mechanical lift for transfers. The facility's investigation summary included a statement that the police were notified, but verification with the police department revealed that no such report was filed. The investigation did not follow the facility's own policy for a comprehensive and prompt investigation of injuries of unknown origin, as required.
Inadequate Supervision and Investigation of Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as R12, remained free from accident hazards and received adequate supervision and assistance devices to prevent accidents. R12, who has severe cognitive impairment and multiple medical conditions including Chronic Kidney Disease and Vascular Dementia, sustained a significant leg injury requiring surgical intervention. The injury occurred when R12 hit her left shin on a sit-to-stand lift during a transfer, leading to a hematoma that later ruptured. The facility did not conduct a thorough investigation to determine how the injury occurred, and the CNA's account of the incident lacked details on how R12's leg was injured. R12's care plan indicated that she was dependent on assistance for mobility and toileting, and she was at risk for falls. Despite this, R12 was left alone on the toilet with the leg strap of the sit-to-stand lift unfastened, which allowed her to move her leg and sustain the injury. The facility's investigation into the incident was inadequate, as it did not explore whether the transfer was completed correctly or how R12's leg came into contact with the lift. Additionally, there was no documentation of interventions to prevent further incidents, and R12 was not observed wearing protective tubi grips as indicated in her care plan. The facility lacked a specific policy and procedure for the use of the sit-to-stand lift, and there was no evidence of education or training provided to staff regarding its safe use. The CNA involved in the incident reported that R12 was left alone on the toilet, and the leg strap was removed, which contributed to the injury. The facility's failure to conduct a thorough investigation and implement appropriate interventions to prevent future incidents highlights a deficiency in ensuring resident safety and adequate supervision.
Deficiency in Dishwashing Sanitation Process
Penalty
Summary
The facility was found to have deficiencies in the dishwashing process, which could potentially affect all 87 residents. During an observation, dietary staff were seen handling dirty items and placing them into the dishwashing machine, then handling clean items without performing hand hygiene or changing their contaminated gloves. This was contrary to the facility's policy, which requires that all flatware, serving dishes, and cookware be washed, rinsed, and sanitized after each use, and that dish machines be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitization. The surveyor observed that the dietary staff did not allow the dishes to air dry and used the same contaminated gloves from loading the dirty used trays to remove the trays once cleaned. The staff member, DS-V, was observed not performing hand hygiene and not changing contaminated gloves between handling used items and then clean items. When questioned, DS-V stated they were not actually touching the items but just the rack. The Kitchen Lead, KL-X, explained the sanitization process to the staff, noting that they were fairly new employees. The concerns were shared with the Nursing Home Administrator and Director of Nurses during the facility exit meeting.
Inadequate Infection Control and Tracking in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, which had the potential to affect all 87 residents, staff, and visitors. The facility did not have documentation of investigations into infection outbreaks, nor did it have a system to track all facility staff illnesses. During a recent COVID-19 outbreak, the facility's line list was incomplete and did not include all staff or document control measures to limit the spread of the virus. Additionally, there was no investigation into how COVID-19 spread across different units, and the facility lacked a specific policy for COVID-19 outbreaks. The facility also failed to implement enhanced barrier precautions for residents with wounds, as required by their infection control policy. During wound care observations, staff did not use enhanced barrier precautions, such as donning gowns, for residents with open wounds. There was no signage or supplies for enhanced barrier precautions outside the rooms of residents with wounds, and the facility's staff were unclear about the requirements for implementing these precautions. Furthermore, the facility did not adequately track staff illnesses, which is crucial for preventing the spread of infections. The facility's system for tracking staff call-ins was incomplete, and there was no trending or tracking information related to staff symptoms, unit worked, or job position. The facility's infection preventionist and director of nursing were responsible for tracking staff illnesses, but they did not have comprehensive information from all departments. This lack of tracking and documentation contributed to the facility's inability to effectively manage and control infection outbreaks.
Failure to Date Opened Insulin Vials
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the dating of insulin vials and pens when opened. During the survey, it was observed that multiple insulin vials and pens across different medication carts and rooms were open and used but not dated when opened. This included Novolog, Lantus, Insulin 70/30, Lispro, and Humulin R vials, some of which were not labeled with a name. The facility's policy requires that the date opened and the shortened expiration date be recorded on multidose vials, which was not adhered to in these instances. The surveyor's observations were made on various floors and units, including the 2nd floor left hall medication cart, 1st floor unit B and A medication carts, and medication rooms on the 2nd floor Cottage Unit and 1st floor [NAME] Court. The facility policy, dated May 2018, specifies that vials and ampules of injectable medications should be used in accordance with the manufacturer's recommendations or the provider pharmacy's directions, and that the date opened must be recorded. Despite this policy, the surveyor found several instances where insulin vials were not dated, indicating a lapse in adherence to the facility's medication management protocols.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that it was safe and clinically appropriate for residents to self-administer medications, as observed in three cases. Resident R63 was found with medications at their bedside without an assessment, physician's order, or care plan for self-administration. Despite having a mental status score indicating no cognitive impairment, there was no documentation supporting the safety and appropriateness of self-administration for R63. Resident R75 was observed with medication cups left on their breakfast tray, which they self-administered without a formal assessment or care plan in place. The resident reported that staff routinely left medications for them to take with breakfast, but there were no orders or assessments to support this practice. This lack of documentation and oversight indicates a failure to ensure the resident's ability to safely self-administer medications. Resident R56 was found with several bottles of medication at their bedside, none of which had pharmacy labels or physician orders. The resident's medical record lacked an assessment to determine their ability to self-administer medications safely, and there was no individualized care plan. Although a self-administration assessment was eventually completed, it was not in place at the time of the surveyor's observation, highlighting a deficiency in the facility's process for managing self-administration of medications.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification of transfer, including appeal rights, to three residents who were transferred to the hospital due to changes in their conditions. Specifically, the facility did not provide written notification to the residents or their representatives, nor did they notify the State Ombudsman as required. This deficiency was identified for three residents: one who was transferred on October 12, 2024, another on December 31, 2024, and a third on June 13, 2024. In each case, the facility lacked documentation of the required notifications. Interviews with the Nursing Home Administrator and Director of Nursing revealed that floor nursing staff were responsible for providing the written notifications, while the facility's Social Worker was tasked with notifying the ombudsman in certain situations. However, the facility was unable to produce the necessary documentation for the transfers of the three residents. The surveyor's review of the medical records and interviews with staff confirmed the absence of the required notifications, highlighting a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to three residents (R62, R283, and R67) when they were transferred to the hospital. R62 was transferred on 10/12/24 due to a change in condition, but the facility did not have a written notice of the bed hold policy for this transfer. Similarly, R283 was transferred on 12/31/24, and the facility again failed to provide the required written notice. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that floor nursing staff were responsible for providing the notice, but it was not done in these cases. R67, who had multiple medical conditions including chronic congestive heart failure and type 2 diabetes mellitus, was transferred to the hospital on 6/13/24 after experiencing severe symptoms. Despite the severity of the situation, there was no evidence that a bed hold notice was provided to R67 or his representative. The facility provided an eInteract transfer form, but it lacked the necessary regulatory information regarding the bed hold policy. The NHA was informed of these deficiencies, but no additional information was provided to address the issue.
Failure to Assess Catheter Necessity for Resident
Penalty
Summary
The facility failed to ensure that a resident who was admitted without an indwelling catheter and later returned from hospitalization with a Foley catheter was assessed for the necessity of the catheter. The resident, who had diagnoses including hypertensive chronic kidney disease, anemia, and vascular dementia, was observed with a catheter upon return to the facility. The hospital discharge summary did not document any genitourinary problems or provide a clinical indication for the catheter's use. Despite this, the facility did not assess the resident for catheter removal or obtain valid medical justification for its continued use. The resident's medical records and interviews with the resident's son revealed that the catheter was not present before hospitalization and was not justified by any documented medical condition upon return. A hospice progress note later indicated the catheter was necessary for end-of-life care, but this was not supported by a valid diagnosis. The facility's failure to assess the necessity of the catheter and the lack of documentation for its use led to the deficiency identified by the surveyor.
Deficiency in Sling Availability for Resident Transfers
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, received reasonable accommodation of needs due to the unavailability of appropriate slings for a Hoyer mechanical lift. R1, who was admitted with diagnoses including fractures, Alzheimer's disease, dementia, and seizure disorder, was dependent on staff for transfers. During the survey, it was observed that slings were not readily available, and staff had to search different units or the laundry to find the correct size. This issue potentially affected 24 out of 87 residents who required similar transfers. Interviews with staff revealed that there was a longstanding shortage of slings, and staff often had to 'eyeball' residents to choose a sling based on convenience rather than a proper guide. Although a chart indicating sling sizes was put up, it lacked a weight guide, and slings were not consistently available on linen carts as expected. The Occupational Therapist reported an incident where R1 could not be transferred due to the unavailability of a sling, and the Unit Manager was informed but did not recall any concerns about sling availability. The Nursing Home Administrator and Director of Nursing were unaware of the shortage and stated that slings should be available on linen carts or in resident rooms. However, during the survey, no slings were found on the carts, and staff confirmed the ongoing issue. The deficiency was highlighted by the surveyor, who noted that slings were necessary for weighing residents upon admission, indicating a need for them to be consistently available regardless of immediate necessity for transfers.
Failure to Provide Proper Care for Surgical Incisions
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for surgical incision wounds. The resident, who was admitted with surgical incision wounds, did not have comprehensive assessments or orders in place for the care of these incisions. The resident's skin integrity care plan did not reflect the presence of surgical wounds, and there was no documentation of the surgical incisions in the resident's medical records. Upon admission, the nursing staff documented the resident's skin as intact, failing to note the three surgical incisions. The facility's medication and treatment administration records did not include orders for monitoring the surgical incisions until the day the resident was discharged. Interviews with staff revealed a lack of awareness and documentation regarding the resident's surgical wounds, and the necessary assessments and care plans were not implemented. The surveyor's findings highlighted that the facility's staff, including the wound nurse and unit manager, did not conduct the required assessments or establish care plans for the resident's surgical incisions. The nursing home administrator and director of nursing acknowledged the oversight and the absence of appropriate care and monitoring for the resident's surgical wounds during their stay at the facility.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and the implementation of assistance devices to prevent accidents for a resident who was reviewed for falls. The resident, who had multiple diagnoses including encephalopathy, diabetes, and visual loss, experienced two falls on the same day. The first fall occurred in the morning when the resident was found sitting on the bathroom floor, confused and with no visible injuries. Despite the resident's care plan indicating the need for a fall mat, it was not in place at the time of the fall. The facility's fall investigation did not include a root cause analysis or statements from staff who might have witnessed the incident, leaving gaps in understanding how the fall occurred. Later that day, the resident experienced a second fall, resulting in facial lacerations and a hospital visit. Again, the fall mat was not in place as per the care plan, and the facility's documentation was inconsistent regarding the circumstances of the fall. The CNA who found the resident did not provide details about the room's setup or the resident's activities prior to the fall. Interviews with staff revealed confusion and lack of clarity about the events leading to the fall, and the facility's investigation did not adequately address these issues. The facility's failure to conduct thorough investigations and implement necessary interventions, such as the fall mat, contributed to the resident's repeated falls and injuries. The lack of detailed documentation and staff statements further hindered the facility's ability to prevent future incidents. The report highlights the need for comprehensive fall prevention measures and thorough investigations to ensure resident safety.
Failure to Provide Timely Catheter Care Orders
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services related to catheter care. The resident was admitted with a Foley catheter but did not have orders in place for catheter care and monitoring until several days after admission. The facility's policy requires that nursing staff assess catheter use and obtain physician orders upon admission, but this was not done in a timely manner for the resident. The resident had multiple diagnoses, including fractures, muscle weakness, cognitive communicative deficit, Alzheimer's disease, dementia, and a urinary tract infection with urinary retention. Despite these conditions, the necessary orders for catheter care and monitoring were delayed, and the facility did not provide a reason for this oversight. The unit manager and director of nursing acknowledged that standing orders should have been implemented upon admission, but this did not occur, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 732 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Berlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clement Manor Health Care Center | 3.1 mi | ★★★★★ | 20 | 1 |
| Maplewood Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Resolve At West Allis Respiratory And Rehab | 3.5 mi | ★★★★★ | 24 | 0 |
| Complete Care At Hales Corners | 4 mi | ★★★★★ | 5 | 0 |
| St Camillus Health Center | 4 mi | ★★★★★ | 0 | 0 |
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 October 2026) and official state health department websites.