Lindengrove Waukesha, Waukesha, WI

The Essentials

Summary

Across 6 inspections from February 2023 to January 2026, state surveyors documented 47 findings at Lindengrove Waukesha; 47 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections: 6; 2023–2026, complaint and standard
Findings: 47; Deficiencies cited by state inspectors
Corrected: 47; Of 47 findings, with a recorded correction date
Penalties: 2; 2 fines; payment not published

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2023	1	5	0
2024	2	25	1
2025	2	16	1
2026	1	1	0

What the Record Shows

47 of 47 findings have a recorded correction date.
CMS lists 2 enforcement actions in the window: 2 fines totaling $204,321, their payment not published.
5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, September 25, 2025, recorded 13 findings (most serious: Level J).

What to Ask About

Pressure Injury Care, Cited in Four Inspections
Care Plans, Cited in Three Inspections
Quality of Care, Cited in Three Inspections
Accident Hazards and Supervision, Cited in Three Inspections
Citation F552, Cited in Two Inspections
Telling Families About Changes, Cited in Two Inspections
Citation F628, Cited in Two Inspections
Continence and Catheter Care, Cited in Two Inspections
Pharmacy Services, Cited in Two Inspections
Psychotropic Medications, Cited in Two Inspections
Medication Error Rate, Cited in Two Inspections
Infection Control, Cited in Two Inspections

Report at a Glance

Facility: Lindengrove Waukesha
Address: 425 N University Dr, Waukesha, WI 53188
CMS Certification Number: 525422
Provider Type: Skilled nursing facility
Certified Beds: 61
Ownership: Non profit - Corporation
Record Window: February 13, 2023 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Jan 212026
Complaint investigation
1 finding
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Feb 10, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Sep 252025
Standard health inspection
13 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Oct 23, 2025
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Oct 23, 2025
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level ENo actual harm, potential for moreCorrected Oct 23, 2025
- F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected Oct 23, 2025
- F946Provide training in compliance and ethics.Level ENo actual harm, potential for moreCorrected Oct 23, 2025
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Oct 23, 2025
Enforcement Action
Civil money penalty, $164,700 imposed September 25, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 25, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 292025
Complaint investigation
3 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 18, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 18, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 18, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jun 112024
Standard health inspection
20 findings
The same visit included a complaint investigation.
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Jul 10, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jul 10, 2024
- F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Jul 10, 2024
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F584Honor 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.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Jul 10, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F758Implement 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.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jul 10, 2024
Enforcement Action
Civil money penalty, $39,621 imposed June 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 11, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Mar 272024
Complaint investigation
5 findings
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Apr 27, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 27, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 27, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Apr 27, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 27, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 132023
Standard health inspection
5 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 14, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 13, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 20, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 17, 2023
- F758Implement 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.Level DNo actual harm, potential for moreCorrected Mar 9, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Pressure Injury Care, Cited in Four Inspections
Inspectors cited F686 in March 2024, June 2024, May 2025 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F686 across all 6 inspections, oldest to newest
2
Care Plans, Cited in Three Inspections
Inspectors cited F656 in February 2023, June 2024 and September 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F656 across all 6 inspections, oldest to newest
3
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in February 2023, May 2025 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F684 across all 6 inspections, oldest to newest
4
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in March 2024, June 2024 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F689 across all 6 inspections, oldest to newest
5
Citation F552, Cited in Two Inspections
Inspectors cited F552 in June 2024 and September 2025. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F552 across all 6 inspections, oldest to newest
6
Telling Families About Changes, Cited in Two Inspections
Inspectors cited F580 in February 2023 and June 2024. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F580 across all 6 inspections, oldest to newest
7
Citation F628, Cited in Two Inspections
Inspectors cited F628 in September 2025 and January 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F628 across all 6 inspections, oldest to newest
8
Continence and Catheter Care, Cited in Two Inspections
Inspectors cited F690 in March 2024 and June 2024. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F690 across all 6 inspections, oldest to newest
9
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in June 2024 and May 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F755 across all 6 inspections, oldest to newest
10
Psychotropic Medications, Cited in Two Inspections
Inspectors cited F758 in February 2023 and June 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F758 across all 6 inspections, oldest to newest
11
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in June 2024 and September 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F759 across all 6 inspections, oldest to newest
12
Infection Control, Cited in Two Inspections
Inspectors cited F880 in February 2023 and March 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424252526F880 across all 6 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in four inspections, most seriously at level J.
02
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in three inspections, most seriously at level D.
03
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level D.
04
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level J.
05
What changed after F552 was cited, and how do you check it now?
Citation F552: cited in two inspections, most seriously at level D.
06
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in two inspections, most seriously at level D.
07
What changed after F628 was cited, and how do you check it now?
Citation F628: cited in two inspections, most seriously at level E.
08
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
09
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
10
How many residents take psychotropic medications, and how often are doses reviewed for reduction?
Psychotropic Medications: cited in two inspections, most seriously at level D.
11
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level D.
12
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
13
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
14
What led to the 2025 fine, and has it been paid?
A $164,700 civil money penalty was imposed September 25, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Feb 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Mar 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jun 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection May 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Sep 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jan 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 525422
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowFebruary 13, 2023 – October 1, 2026

CMS publishes about three inspection cycles; inspections before February 2023 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.