Cycle 1
Health 2025-09-25 · Fire 2025-09-25
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Waukesha, WI
Lindengrove Waukesha
1-star overall rating with 1-star inspections with $39,621 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
425 N University Dr, Waukesha, WI
(262) 524-6400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-02-24
CMS approved date
Coverage
Medicare
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
0.89
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,702
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.98
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
Baseline 23.55% · Performance 24.93% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.64% · Performance 9.60% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 52.17% · Performance 82.54% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.39
Performance 4.33 hours · Measure score 4.39 · Achievement 4.39 · 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 | 12.33% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 15.13% · Lower 95% interval 9.48% |
| Discharge to community | 42.06% |
50.57%
8.5 pts worse
|
Worse than the National Rate · Eligible stays 156 · Observed rate 36.54% · Lower 95% interval 33.77% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.73% |
95.27%
3.5 pts better
|
Numerator 78 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 39.29% |
53.69%
14.4 pts worse
|
Numerator 22 · Denominator 56 |
| Discharge mobility score | 26.79% |
50.94%
24.1 pts worse
|
Numerator 15 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 3.8% |
2.29%
1.5 pts worse
|
Numerator 3 · Denominator 79 · Adjusted rate 4.16% |
| Healthcare-associated infections requiring hospitalization | 9.6% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 12.63% · Lower 95% interval 5.78% |
| Staff COVID-19 vaccination coverage | 3.6% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 111 |
| Staff flu vaccination coverage | 45.45% |
42%
3.5 pts better
|
Numerator 65 · Denominator 143 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 21 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 2 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 4.1 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.6 |
2.2
2.4 pts worse
|
1.8
2.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.6 · Observed 6.3 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.9% |
95.7%
20.8 pts worse
|
93.4%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.7% · Q2 74.5% · Q3 74.4% · Q4 79.5% · 4Q avg 74.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 63.3% |
95.0%
31.7 pts worse
|
95.5%
32.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 63.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.2%
3.4 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.1% · Q3 9.3% · Q4 9.1% · 4Q avg 6.6% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 9.9% |
4.9%
5 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 7.7% · Q3 13.2% · Q4 5.9% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
16.6%
6.4 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 7.3% · Q3 10.5% · Q4 11.1% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
16.7%
1.1 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 18.2% · Q3 12.1% · Q4 17.2% · 4Q avg 17.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.6% |
21.1%
1.5 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
17.3%
3.1 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 17.9% · Q3 13.9% · Q4 18.2% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.1% |
2.3%
3.8 pts worse
|
1.0%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 1.6% · Q3 3.0% · Q4 13.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
3.0%
1.9 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 2.2% · Q3 4.7% · Q4 2.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
25.5%
4.5 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 20.5% · Q3 22.7% · Q4 38.2% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.5%
1.5 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.7% · Q3 4.8% · Q4 8.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.0% |
86.8%
17.8 pts worse
|
81.7%
12.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 69.5% · Q3 66.0% · Q4 67.9% · 4Q avg 69.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
15.0%
4.3 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 18.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.5% |
82.2%
34.7 pts worse
|
79.7%
32.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
22.7%
7.1 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 29.7% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-11 · Fire 2024-06-11
25 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-02-13 · Fire 2023-02-13
5 health deficiencies
Top issue: Infection Control (1 deficiency)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-09-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-17
E · Potential for more than minimal harm
2025-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-17
E · Potential for more than minimal harm
2025-09-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-09-25
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-09-25
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-12-17
F · Potential for more than minimal harm
2024-06-11
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-06-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-10
F · Potential for more than minimal harm
2023-02-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-02-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-25
F · Potential for more than minimal harm
2023-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-02-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-11
F · Potential for more than minimal harm
2023-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-02-13
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-02-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-02-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-25
E · Potential for more than minimal harm
2023-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-02-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-02-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-02-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-10
J · Immediate jeopardy
2025-09-25
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 2025-10-23
E · Potential for more than minimal harm
2025-09-25
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-23
E · Potential for more than minimal harm
2025-09-25
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-10-23
E · Potential for more than minimal harm
2025-09-25
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-10-23
E · Potential for more than minimal harm
2025-09-25
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-25
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 2025-10-23
D · Potential for more than minimal harm
2025-09-25
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 2025-10-23
D · Potential for more than minimal harm
2025-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-25
F849 · Administration Deficiencies
Health
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.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-29
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 2025-06-18
J · Immediate jeopardy
2024-06-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-11
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 2024-07-10
E · Potential for more than minimal harm
2024-06-11
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
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 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
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 2024-07-10
D · Potential for more than minimal harm
2024-06-11
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 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
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 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-10
C · Minimal harm
2024-06-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-03-27
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 2024-04-27
D · Potential for more than minimal harm
2024-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-27
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 2024-04-27
D · Potential for more than minimal harm
2024-03-27
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 2024-04-27
D · Potential for more than minimal harm
2024-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-27
E · Potential for more than minimal harm
2023-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-13
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 2023-03-20
D · Potential for more than minimal harm
2023-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-13
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-09
Penalties and ownership
What sits behind the stars
$39,621
2024-06-11
Fine
Fine · fine $39,621
Fine
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
Kohlhoff, Kevin
Corporate Director · Individual
Konkol, Dennis
Corporate Director · Individual
Lembke, Adam
Operational/Managerial Control · Individual
Marks, Julie
Operational/Managerial Control · Individual
Marks, Julie
Corporate Officer · Individual
Mauthe, Matthew
Operational/Managerial Control · Individual
Mauthe, Matthew
Corporate Officer · Individual
Meidenbauer, Robert
Corporate Director · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Van Der Linden, Katie
Corporate Director · Individual
Wagner, Lynne
Corporate Director · Individual
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#3
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1-star overall rating with 2-star inspections with $26,480 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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