Inspection visit
Inspection
Citations
29 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0311GeneralS&S Dpotential for harm
Have an enclosure around a vertical opening shaft.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
- 0541GeneralS&S Dpotential for harm
Install properly constructed and protected linen or trash chutes.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F925 - Maintain an effective pest control program so that the facility is free of
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
FAQ · About this visit
Common questions about this visit
What happened during the March 3, 2025 survey of Lindengrove Menomonee Falls?
This was a inspection survey of Lindengrove Menomonee Falls on March 3, 2025. The surveyor cited 29 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Lindengrove Menomonee Falls on March 3, 2025?
Yes, 29 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.