Lindengrove Waukesha
425 N University Dr, Waukesha, WI 53188
Lindengrove Waukesha is a nursing home in Waukesha, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionSeptember 25, 2025 (1 year ago)
- Health citations since February 13, 202347 (Wisconsin average 28)
- Fines in the past three years2, $204,321 in total
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of March 25, 2026
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of February 25, 2026
Health citation
CMS changed citation F0686 from severity G to D. It is from the health inspection on March 27, 2024. Severity D: potential for more than minimal harm, isolated.
Health inspection on January 21, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on February 10, 2026.
CMS has cited this home for F0628 2 times since 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on September 25, 2025
13 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $164,700 on September 25, 2025.
Show the 13 citations
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 23, 2025.
CMS has cited this home for F0689 3 times since 2024.
Citation F0628. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on October 23, 2025.
Citation F0941. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on October 23, 2025.
Citation F0944. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on October 23, 2025.
Citation F0946. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on October 23, 2025.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on October 23, 2025.
CMS has cited this home for F0552 2 times since 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 23, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 23, 2025.
CMS has cited this home for F0656 3 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 23, 2025.
CMS has cited this home for F0684 3 times since 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 23, 2025.
CMS has cited this home for F0686 4 times since 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on October 23, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on October 23, 2025.
CMS has cited this home for F0759 2 times since 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 23, 2025.
Fire safety inspection on September 25, 2025
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on December 17, 2025.
CMS has cited this home for E0039 2 times since 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 17, 2025.
CMS has cited this home for K0712 3 times since 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 17, 2025.
CMS has cited this home for K0353 2 times since 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 17, 2025.
CMS has cited this home for K0372 2 times since 2024.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on December 17, 2025.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on December 17, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on May 29, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 18, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 18, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 18, 2025.
CMS has cited this home for F0755 2 times since 2024.
CMS update of April 30, 2025
Staffing
Total nurse staffing reported to CMS went from 5.0 to 4.4 hours per resident per day.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Fine
CMS changed the fine from June 11, 2024 from $60,955 to $39,621.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 5.2 to 3.7 hours per resident per day.
Health inspection on June 11, 2024
20 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $39,621 on June 11, 2024.
Show the 20 citations
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 10, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 10, 2024.
Citation F0576. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on July 10, 2024.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on July 10, 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on July 10, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 10, 2024.
CMS has cited this home for F0580 2 times since 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 10, 2024.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on July 10, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 10, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 10, 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on July 10, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 10, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 10, 2024.
CMS has cited this home for F0690 2 times since 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 10, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 10, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 10, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on July 10, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on July 10, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 10, 2024.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on July 10, 2024.
Fire safety inspection on June 11, 2024
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation E0009. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on July 10, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 10, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on July 10, 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on July 10, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on July 10, 2024.
CMS has cited this home for K0920 2 times since 2023.
CMS update of April 25, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on March 27, 2024
5 citationsCMS lists this as a complaint inspection.
Show the 5 citations
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 27, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 27, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 27, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on April 27, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 27, 2024.
CMS has cited this home for F0880 2 times since 2023.
CMS update of January 31, 2024
Staffing
Total nurse staffing reported to CMS went from 6.3 to 5.2 hours per resident per day.
CMS update of December 21, 2023
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
Name
CMS lists a new legal business name for this home.
Health inspection on February 13, 2023
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 14, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on March 13, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 20, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 17, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 9, 2023.
Fire safety inspection on February 13, 2023
16 citationsCMS lists this as a standard inspection.
Show the 16 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on March 1, 2023.
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on April 25, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 24, 2023.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on March 31, 2023.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on February 11, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 6, 2023.
Citation K0132. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
CMS lists it as corrected on March 24, 2023.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on March 24, 2023.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on April 25, 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 10, 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 10, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 25, 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on February 9, 2023.
Citation K0362. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on March 7, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 10, 2023.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on February 10, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 1 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (262) 524-6400
- Last standard health inspection
- September 25, 2025 (1 year ago)
- Certified beds
- 61
- Residents per day, on average
- 55
- Ownership type
- Non profit - Corporation
- Legal business name
- Lindengrove Communities LLC
- Chain
- Not listed by CMS
- Takes part in
- Medicare
More health citations than the Wisconsin average (47 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MARQUARDT VILLAGE INC5% or greater indirect ownership interest · 100% · since 03/07/2023
- ILLUMINUS INCOperational/managerial control · not applicable · since 03/20/2023
- LEMBKE, ADAMOperational/managerial control · not applicable · since 03/20/2023
- MARKS, JULIEOperational/managerial control · not applicable · since 06/05/2025
- MAUTHE, MATTHEWOperational/managerial control · not applicable · since 03/20/2023
Show 1 more
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 11/16/2020
Questions
When was Lindengrove Waukesha last inspected?
CMS lists September 25, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Lindengrove Waukesha have?
CMS lists 47 health citations since February 13, 2023. CMS also calls these deficiencies.
Has Lindengrove Waukesha been fined?
CMS lists 2 fines in the past three years, $204,321 in total.
What is the CMS star rating of Lindengrove Waukesha?
Its CMS overall star rating is 1 of 5.
Is Lindengrove Waukesha a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.