A list of the most recent deficiencies for Lindengrove Waukesha. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-02-09 | 2023-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-09 | 2023-04-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-09 | 2023-04-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-09 | 2023-03-31 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-02-09 | 2023-03-24 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-09 | 2023-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-13 | 2023-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-13 | 2023-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-13 | 2023-03-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-13 | 2023-03-13 | N |
| 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. | Health | 2023-02-13 | 2023-03-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-02-09 | 2023-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-09 | 2023-03-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-09 | 2023-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-09 | 2023-02-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-09 | 2023-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-09 | 2023-02-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-09 | 2023-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-09 | 2023-02-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-09 | 2023-02-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-09 | 2023-02-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-04 | 2022-02-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-04 | 2022-02-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-04 | 2022-02-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-04 | 2022-02-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-05 | 2022-01-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-05 | 2022-01-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-01-05 | 2022-01-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-01-05 | 2022-01-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-05 | 2022-01-07 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-11 | 2021-06-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-06 | 2019-12-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-12-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-06 | 2019-12-06 | N |
| 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. | Health | 2019-11-06 | 2019-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-06 | 2019-12-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
