Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lindengrove Waukesha
WAUKESHA, WI · 61 certified beds · Last Life Safety survey September 25, 2025
CMS Certification Number 525422 · 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
27 citations — more than 77% 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 6 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was September 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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3 inspection-and-testing tags have 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
3 of the 27 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)
6 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 27 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 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-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 | 27 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 13, 2023 | 16 |
| June 11, 2024 | 5 |
| September 25, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-09-25 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-09-25 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-06-11 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-09-25 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-09-25 |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | 1 | 2023-02-13 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2024-06-11 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2024-06-11 |
What the citations cover
- Smoke Deficiencies 10
- Miscellaneous Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Miscellaneous Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 25, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (December 17, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (December 17, 2025) |
June 11, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 10, 2024) |
February 13, 2023 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 1, 2023) |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (March 24, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (March 24, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 25, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 24, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 9, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (March 7, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 31, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (February 11, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (February 10, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.