Lindengrove Waukesha: Abuse Report Filing Failure - WI
That sequence, documented in a September 2025 inspection report, is the center of what federal surveyors found at the Waukesha facility during a complaint investigation. The inspection covered a single tag, F0609, which addresses the requirement that nursing homes report allegations of abuse to state agencies. The harm level was classified as minimal or potential. The number of residents affected was listed as few. Neither of those designations captures what it feels like to be an elderly person who was screamed at by someone paid to care for you, and then to watch the people running your facility treat it as something that sorted itself out.
The resident at the center of this is identified in inspection records only as R30. What the records do say is that R30 told a surveyor that a facility staff member screamed at R30 and scared R30. That's the language in the report, plain and without elaboration: screamed at, and scared. The surveyor passed that information to the facility's nursing home administrator, identified as NHA-A, on September 8, 2025, at 2:56 in the afternoon.
The next day, at 2:37 in the afternoon, the surveyor came back and raised the issue again. The abuse allegation had still not been reported to the state agency. More than twenty hours had passed.
NHA-A's explanation was that R30 had not brought it up when facility staff went to speak with R30 the previous day. That was the reason offered. R30 hadn't mentioned it during the facility's own follow-up visit, so the administrator hadn't treated it as something requiring a formal report.
The surveyor did not accept that reasoning, and the inspection record makes clear why. R30 had made the allegation directly to the surveyor. Once the surveyor informed NHA-A of what R30 said, the clock on reporting started. It doesn't matter that R30 didn't repeat the allegation to the staff members who came to check on them afterward. The facility had been told.
The staff member R30 had concerns about, identified in the report as CNA-F, no longer worked at the facility. According to NHA-A, CNA-F's last day of employment was August 5, 2025, more than a month before the inspection. The surveyor reviewed CNA-F's employee file and confirmed that date.
A second staff member, CNA-E, had apparently been aware that R30 had concerns and knew which colleague R30 was referring to. The inspection record notes that CNA-E had received a concern from R30 and had been educated afterward on the facility's grievance process. A grievance was eventually filed, but the records suggest it was filed after the surveyor's involvement, not as a prompt response to what R30 originally reported.
NHA-A told the surveyor on September 9 that the situation had been one isolated incident, that everything was good, and that the staff member in question no longer worked there. The administrator acknowledged that the concern should have been brought to a nurse's attention and that the grievance process should have been followed. Those admissions are in the record.
What the record also shows is that a resident described being screamed at and scared, and the facility's initial response was to speak with that resident informally, conclude that things were fine, and move on. The formal machinery of abuse reporting, the state agency notification that exists specifically so that someone outside the facility is watching, did not activate until a federal inspector made clear it was supposed to.
That gap is not incidental. The abuse reporting process in nursing homes exists because facilities cannot be trusted to investigate themselves without outside accountability. When a resident tells a surveyor something they apparently didn't feel comfortable repeating to facility staff, that itself is information. It suggests something about the environment R30 was living in, about who felt safe to tell what to whom.
R30 is described in the report as having had no further concerns about verbal interactions with staff following the incident. The staff member who scared them was already gone before any of this came to light. In one sense, the situation had resolved on its own, which is probably why NHA-A described it the way he did.
But resolution and accountability are different things. A staff member screamed at a vulnerable person in their care. That person was scared. The person who did it left the job. The people responsible for running the facility learned what had happened and did not tell the state. They told the inspector everything was good.
The inspection found no evidence that additional residents had been affected, no pattern of similar incidents, no broader breakdown in how the facility handled abuse concerns. The deficiency was cited at the lower end of the harm scale. Facilities receive citations like this and continue operating, continue admitting residents, continue being the place where people who can no longer care for themselves go to live.
R30 is still there.
The inspection report does not say whether R30 knew that the concern they raised to a federal inspector sat unreported for more than a day. It does not say whether anyone at the facility told R30 what happened next, or what the grievance that was eventually filed contained, or whether R30 was told that the staff member who scared them had already been gone for weeks before any of this came to a head. The report ends where inspection reports end, with findings and dates and the administrator's explanations.
What R30 experienced on the day someone screamed at them, and what R30 felt in the weeks between that day and the day a surveyor came and asked questions, is not in the record. It rarely is.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lindengrove Waukesha from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
Lindengrove Waukesha in WAUKESHA, WI was cited for abuse-related violations during a health inspection on September 25, 2025.
The inspection covered a single tag, F0609, which addresses the requirement that nursing homes report allegations of abuse to state agencies.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.