LINDENGROVE MENOMONEE FALLS
Open-data reference.
LINDENGROVE MENOMONEE FALLS is a non profit - corporation facility in MENOMONEE FALLS, WI with 73 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $142K.
W180 N8071 TOWN HALL RD, MENOMONEE FALLS, WI 53051
Phone: 2622532700
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525421
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 73
- Residents
- 48
- In Hospital
- No
- County
- Waukesha
- Last Inspection
- Mar 3, 2025
Staffing Data
- RN Hours
- 0.59 (nat'l avg: 0.68)
- LPN Hours
- 0.86
- CNA Hours
- 2.50
- Total Nursing Hours
- 3.95 (nat'l avg: 3.89)
- PT Hours
- 0.10
- Nursing Turnover
- 65.3%
- RN Turnover
- 62.5%
What the CMS Record Reveals About LINDENGROVE MENOMONEE FALLS
LINDENGROVE MENOMONEE FALLS operates 73 certified beds in MENOMONEE FALLS, WI with approximately 48 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 6 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $142K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.95 total nursing hours per resident day (national average 3.89), with RN coverage at 0.59 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, LINDENGROVE MENOMONEE FALLS falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 65.3%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Dec 8, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 8, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 12, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 6, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 8, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Dec 8, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 19, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 19, 2025
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 15, 2025
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 15, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 15, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Category: Resident Rights Deficiencies
Corrected: Aug 15, 2025
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Aug 15, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 2, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 2, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 2, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 2, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 2, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 2, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Apr 2, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 2, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 2, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 2, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Apr 2, 2025
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 2, 2025
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 2, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 2, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 2, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 2, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 2, 2025
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.
Category: Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Apr 2, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Apr 2, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 25, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 25, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 16, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 16, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 16, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 16, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 16, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Feb 16, 2024
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 16, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 16, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: May 7, 2023
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category: Infection Control Deficiencies
Corrected: May 7, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: May 7, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 28.9% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 15.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.4% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 92.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 82.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.2% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 46.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 3.5% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 94.4% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 77.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 24.6% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 4.2% | Yes |
Penalty History 2 penalties totaling $142K
| Date | Type | Amount |
|---|---|---|
| Mar 3, 2025 | Fine | $79K |
| Jan 17, 2024 | Fine | $64K |
| Jan 17, 2024 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for LINDENGROVE MENOMONEE FALLS?
What are the staffing levels at LINDENGROVE MENOMONEE FALLS?
How many beds does LINDENGROVE MENOMONEE FALLS have?
Does LINDENGROVE MENOMONEE FALLS have any deficiencies on record?
Has LINDENGROVE MENOMONEE FALLS received any fines or penalties?
Who owns LINDENGROVE MENOMONEE FALLS?
When was LINDENGROVE MENOMONEE FALLS last inspected?
What quality measures are tracked for LINDENGROVE MENOMONEE FALLS?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.