Federal inspection record · CMS data as of October 1, 2026
Lindengrove Waukesha
425 N University Dr, Waukesha, WI · (262) 524-6400
- Certified beds
- 61
- Residents per day
- 55
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare
- Certified since
- February 24, 1989
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Wisconsin.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 1)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Wisconsin homes
Lindengrove Waukesha carries 156 inspection points. That is fewer than 16% of Wisconsin's 321 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Wisconsin: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–11 pts
- 4★ 11–37 pts
- 3★ 37–76 pts
- 2★ 76–130.75 pts
- 1★ over 130.75 pts
Bars show every rated home in Wisconsin by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
47 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Quality of Life and Care13D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide activities to meet all resident's needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights10E
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- E
Ensure residents have reasonable access to and privacy in their use of communication methods.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
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.
- D
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.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Pharmacy Service9D
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
- D
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.
- D
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.
Administration4E
- E
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- E
Provide training in compliance and ethics.
- D
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.
Resident Assessment and Care Planning4D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Infection Control2E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Inspection history
2025-09-25
14 health deficiencies · 6 fire-safety deficiencies
Top issue: Administration (4 deficiencies)
2024-06-11
23 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2023-02-13
10 health deficiencies · 16 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 1 min of nursing staff time a day, 48 min of it from a registered nurse.
This home
4 h 1 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 68% of nursing staff and 71% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$204,321 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-09-25 | Fine | $164,700 |
| 2024-06-11 | Fine | $39,621 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine13.6 pts worse | 82.4% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine7.4 pts worse | 88.2% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury4.4 pts worse | 7.7% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6 pts better | 0.0% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight2 pts worse | 6.9% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.3 pts better | 11.5% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication1.9 pts better | 14.0% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened3.9 pts worse | 20.9% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.9 pts worse | 19.7% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder6.1 pts worse | 8.0% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection4 pts worse | 6.7% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence10.7 pts worse | 34.3% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3 pts worse | 7.9% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11 pts worse | 75.9% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit14 pts worse | 29.6% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.7 pts better | 0.5% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine25.5 pts worse | 56.7% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.8 pts worse | 26.3% | 22.5% | 23.4% |
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Who owns and runs it
22 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Marquardt Village Inc | 5% Or Greater Indirect Ownership Interest · Organization | 100% | 6 facilities |
| Dettman, Scott | Corporate Director · Individual | 0% | 8 facilities |
| Fischer, Todd | Managing Control - Governing Body · Individual | 0% | 8 facilities |
| Fischer, Todd | Corporate Director · Individual | 0% | 8 facilities |
| Heroux, Steven | Corporate Director · Individual | 0% | 7 facilities |
| Illuminus Inc | Operational/Managerial Control · Organization | 0% | 11 facilities |
| Illuminus Inc | Adp Of The SNF · Organization | 0% | 11 facilities |
| Kohlhoff, Kevin | Corporate Director · Individual | 0% | 7 facilities |
| Konkol, Dennis | Corporate Director · Individual | 0% | 7 facilities |
| Lembke, Adam | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Lembke, Adam | Adp Of The SNF · Individual | 0% | 1 facilities |
| Marks, Julie | Corporate Officer · Individual | 0% | 11 facilities |
| Marks, Julie | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Marks, Julie | Adp Of The SNF · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Corporate Officer · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Mauthe, Matthew | Adp Of The SNF · Individual | 0% | 11 facilities |
| Meidenbauer, Robert | Corporate Director · Individual | 0% | 8 facilities |
| Sidhu, Sarfraz | Operational/Managerial Control · Individual | 0% | 28 facilities |
| Sidhu, Sarfraz | Adp Of The SNF · Individual | 0% | 28 facilities |
| Van Der Linden, Katie | Corporate Director · Individual | 0% | 6 facilities |
| Wagner, Lynne | Corporate Director · Individual | 0% | 7 facilities |
·
Fire safety
27 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Install a fire alarm system that can be heard throughout the facility.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Provide properly protected cooking facilities.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Miscellaneous6F
- F
Have simulated fire drills held at unexpected times.
- D
Have restrictions on the use of highly flammable decorations.
- D
Have restrictions on the use of portable space heaters.
- F
Have simulated fire drills held at unexpected times.
- F
Provide a written emergency evacuation plan.
- F
Have simulated fire drills held at unexpected times.
Emergency Preparedness3F
- F
Conduct testing and exercise requirements.
- F
Include a process for Emergency Preparedness collaboration.
- F
Conduct testing and exercise requirements.
Gas, Vacuum, and Electrical Systems3D
- D
Ensure proper usage of power strips and extension cords.
- D
Ensure proper usage of power strips and extension cords.
- D
Have proper medical gas storage and administration areas.
Services2F
- D
Have properly installed electrical wiring and gas equipment.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Construction2E
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
- E
Use approved construction type or materials.
Egress1E
- E
Have exits that are accessible at all times.
·
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Complete Care at Kensington
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Aria of Waukesha
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