Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lindengrove Menomonee Falls
MENOMONEE FALLS, WI · 73 certified beds · Last Life Safety survey March 3, 2025
CMS Certification Number 525421 · first certified February 1989
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
- Ownership changed March 20, 2023 (change of ownership)from LINDENGROVE, INC.
Position within WI
18 citations — more than 51% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2026 to June 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 15, 2022 | 3 |
| January 17, 2024 | 6 |
| March 3, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-03-03 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-03-03 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2024-01-17 |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | 1 | 2025-03-03 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2025-03-03 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2025-03-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-01-17 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-01-17 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Emergency Preparedness Deficiencies 4
- Smoke Deficiencies 4
- Egress Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 3, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 12, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 12, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 26, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (March 26, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 24, 2025) |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Deficient, Provider has date of correction (March 12, 2025) |
January 17, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 12, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 10, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 10, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 12, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (February 5, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (January 4, 2024) |
September 15, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (October 15, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 15, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 15, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.