Care Citations

Lindengrove Waukesha

425 N UNIVERSITY DR, WAUKESHA, WI, 53188 · 2625246400

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
3 / 5
Certified beds
61
Ownership type
Non profit - Corporation

Inspection findings on record (47)

Quoted exactly as CMS published them. We do not rewrite findings.

— Resident Rights Deficiencies

Tag 0628 · scope/severity D · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity J · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0628 · scope/severity E · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Administration Deficiencies

Tag 0941 · scope/severity E · potential for more than minimal harm

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Recorded as corrected on .

— Administration Deficiencies

Tag 0944 · scope/severity E · potential for more than minimal harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Recorded as corrected on .

— Administration Deficiencies

Tag 0946 · scope/severity E · potential for more than minimal harm

Provide training in compliance and ethics.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Administration Deficiencies

Tag 0849 · scope/severity D · potential for more than minimal harm

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity J · immediate jeopardy

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0576 · scope/severity E · potential for more than minimal harm

Ensure residents have reasonable access to and privacy in their use of communication methods.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity D · potential for more than minimal harm

Allow residents to self-administer drugs if determined clinically appropriate.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity D · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity C · potential for minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0578 · scope/severity D · potential for more than minimal harm

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 525422