Cycle 1
Health 2025-12-10 · Fire 2025-12-10
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mukwonago, WI
Lindengrove Mukwonago
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
837 E Veterans Way, Mukwonago, WI
(262) 363-6830
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-10-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.15
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.24
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,698
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.64
Baseline 21.04% · Performance 21.14% · Measure score 0.64 · Achievement 0.64 · Improvement 0
Healthcare-associated infections
0
Baseline 7.41% · Performance 8.63% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 27.59% · Performance 79.63% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.76
Performance 4.15 hours · Measure score 3.76 · Achievement 3.76 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.03% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 12.88% · Lower 95% interval 9.28% |
| Discharge to community | 44.03% |
50.57%
6.5 pts worse
|
Worse than the National Rate · Eligible stays 157 · Observed rate 41.4% · Lower 95% interval 38.8% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 108 · Denominator 108 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 108 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 33 · Denominator 77 |
| Discharge mobility score | 44.16% |
50.94%
6.8 pts worse
|
Numerator 34 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 108 · Adjusted rate 1.88% |
| Healthcare-associated infections requiring hospitalization | 8.64% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 9.71% · Lower 95% interval 5.24% |
| Staff COVID-19 vaccination coverage | 11.49% |
8.2%
3.3 pts better
|
Numerator 10 · Denominator 87 |
| Staff flu vaccination coverage | 47.42% |
42%
5.4 pts better
|
Numerator 46 · Denominator 97 |
| Discharge function score | 49.35% |
56.45%
7.1 pts worse
|
Numerator 38 · Denominator 77 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 98.51% |
96.28%
2.2 pts better
|
Numerator 66 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 25.42% |
25.2%
0.2 pts better
|
Numerator 15 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.2% |
95.7%
19.5 pts worse
|
93.4%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 73.9% · Q4 91.3% · 4Q avg 76.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 42.9% |
95.0%
52.1 pts worse
|
95.5%
52.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 42.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.5% |
3.2%
6.3 pts worse
|
3.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 8.7% · Q4 8.7% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
4.9%
1.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
16.6%
1.7 pts worse
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
16.7%
2.5 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.0% |
21.1%
8.1 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
17.3%
1.8 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.3%
0.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 6.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
3.0%
0.9 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 8.7% · Q4 5.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
25.5%
3 pts better
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 16.5% |
5.5%
11 pts worse
|
5.1%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 21.4% · Q4 20.2% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
86.8%
2.9 pts worse
|
81.7%
2.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.4% · Q2 85.6% · Q3 84.7% · Q4 87.5% · 4Q avg 83.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
15.0%
1.3 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.2% |
82.2%
28 pts worse
|
79.7%
25.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
22.7%
3.7 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 27.2% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-05 · Fire 2023-04-05
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-10
F · Potential for more than minimal harm
2025-12-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-16
F · Potential for more than minimal harm
2024-07-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-18
E · Potential for more than minimal harm
2024-07-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-06
E · Potential for more than minimal harm
2024-07-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-07-24
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-07-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-26
F · Potential for more than minimal harm
2023-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-04-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-07
E · Potential for more than minimal harm
2025-12-10
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-05-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-03-20
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-12-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-07-24
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-24
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2024-08-23
D · Potential for more than minimal harm
2023-10-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-10-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-04-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-05
Penalties and ownership
What sits behind the stars
$0
2024-07-24
Payment Denial
Payment Denial · denial start 2024-10-24 · 15 days
15 day denial
Ownership
Marquardt Village Inc
5% Or Greater Indirect Ownership Interest · Organization
The Hills At Cortland Ridge, Inc.
5% Or Greater Direct Ownership Interest · Organization
Dettman, Scott
Corporate Director · Individual
Fischer, Todd
Corporate Director · Individual
Heroux, Steven
Corporate Director · Individual
Illuminus Inc
Operational/Managerial Control · Organization
Kim, Steven
Operational/Managerial Control · Individual
Kohlhoff, Kevin
Corporate Director · Individual
Konkol, Dennis
Corporate Director · Individual
Marks, Julie
Operational/Managerial Control · Individual
Marks, Julie
Corporate Director · Individual
Marks, Julie
Corporate Officer · Individual
Mauthe, Matthew
Operational/Managerial Control · Individual
Mauthe, Matthew
Corporate Officer · Individual
Meidenbauer, Robert
Corporate Director · Individual
Van Der Linden, Katie
Corporate Director · Individual
Wagner, Lynne
Corporate Director · Individual
Whitty, Suzanne
Operational/Managerial Control · Individual
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#3
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