Inspection Reports for
Congregational Home
13900 W Burleigh Rd, Brookfield, WI 53005, Brookfield, WI, 13900
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
95% occupied
Based on a February 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 0
Date: Feb 3, 2026
Visit Reason
Surveyor conducted a verification visit and complaint investigation at Congregational Home Inc.
Complaint Details
Complaint was unsubstantiated.
Findings
No deficiencies were identified. The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 27, 2025
Visit Reason
A complaint investigation was conducted to determine if Congregational Home Inc. was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, resulting in issuance of a Statement of Deficiency and enforcement actions including forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #UNVG11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $1,350 was imposed for these violations, with a reduced payment option of $877.50 if not appealed.
Report Facts
Forfeiture amount: 1350
Reduced forfeiture amount: 877.5
Forfeiture amount: 750
Forfeiture amount: 600
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: Oct 27, 2025
Visit Reason
Surveyors conducted a complaint investigation at Congregational Home Inc. due to concerns alleging residents do not receive adequate medical treatment.
Complaint Details
Complaint was substantiated. The investigation was triggered by a concern alleging residents do not receive adequate medical treatment.
Findings
Two deficiencies were identified related to inadequate treatment and assessment of a resident after an unwitnessed fall. The complaint was substantiated.
Deficiencies (2)
83.32(3)(i) Rights of Residents: Adequate treatment. The provider did not ensure one resident received adequate treatment after an unwitnessed fall, including failure to obtain a STAT X-ray promptly, resulting in delayed diagnosis of a fractured hip.
83.35(1)(a) Pre-admission and ongoing assessments. The provider did not ensure an assessment of one resident's physical and mental condition was completed when there was a change in needs, despite the resident sustaining five falls.
Report Facts
Census: 20
Falls sustained: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing I | Director of Nursing | Interviewed regarding the provider's protocol for sending residents out for medical treatment after a fall. |
| Medical Doctor F | Medical Doctor | Physician who responded to the call after Resident 1's fall and ordered STAT X-ray. |
| Chief Executive Officer A | Chief Executive Officer | Interviewed about Resident 1's fall risk assessment and transfer protocol. |
| Power of Attorney G | Power of Attorney | Interviewed about notification of Resident 1's fall and x-ray order. |
| Med Passer C | Interviewed regarding awareness of Resident 1's unwitnessed fall and pain. | |
| Licensed Practical Nurse H | Licensed Practical Nurse | Mentioned to NOC Care Manager regarding Resident 1's severe hip pain. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
An abbreviated survey was conducted to determine if Congregational Home Inc. was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #1W3811) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. A total forfeiture of $1,140.00 was imposed for these violations, with corrective measures and staff training required within 45 days.
Report Facts
Forfeiture amount: 1140
Reduced forfeiture amount: 741
Forfeiture amount: 540
Forfeiture amount: 600
Compliance timeframe: 45
Payment timeframe: 10
Appeal timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Hillary Holman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Abbreviated Survey
Census: 21
Capacity: 21
Deficiencies: 4
Date: Sep 25, 2025
Visit Reason
An abbreviated licensure survey was conducted at Congregational Home Inc. to assess compliance with regulatory requirements and identify deficiencies.
Findings
Four deficiencies were identified including medication administration errors, failure to update individual service plans, improper disposition of expired medications, and inadequate health monitoring of residents.
Deficiencies (4)
83.32(3)(h) Rights of Residents: Receive medication. The provider did not administer medications in the intervals prescribed by a practitioner for 3 residents, including failure to administer medications and administration of expired medications.
83.35(3)(d) Service plans updated annually or on changes. The provider did not update individual service plans to reflect changes in residents' needs for 2 residents, including meal assistance and incontinence care.
83.37(1)(g) Disposition of medications. The provider did not ensure expired medications were separated from current medications and properly disposed of for 4 residents.
83.38(1)(g) Health monitoring. The provider did not ensure appropriate health monitoring, including weight and oxygen level documentation, for 5 residents.
Report Facts
Deficiencies identified: 4
Census: 21
Total Capacity: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director B | Interviewed regarding medication administration errors, service plan updates, expired medication oversight, and health monitoring documentation. | |
| Chief Executive Officer A | Communicated with surveyor regarding medication administration oversight and documentation process improvements. | |
| Registered Nurse D | Registered Nurse | Responsible for oversight of medication cart and interviewed about service plan updates and expired medication concerns. |
| Med Passer C | Observed during medication pass and questioned about medication administration. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 31, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements including resident assessments, safety, and food service standards.
Findings
The facility was found deficient in timely completion and transmission of Minimum Data Set (MDS) assessments, inadequate supervision leading to a resident fall, and improper sanitization procedures in the kitchen dishwashing process. Multiple residents had late or incomplete MDS assessments. One resident fell due to improper assistance during incontinence care. The dish machine was not reaching required sanitization temperatures and the 3-compartment sink sanitizer was not maintained properly.
Deficiencies (5)
F0636: The facility did not complete admission and annual comprehensive MDS assessments within required timeframes for 8 of 12 residents reviewed.
F0638: The facility did not complete quarterly MDS assessments within required timeframes for 2 of 12 residents reviewed.
F0640: The facility did not complete and transmit admission, quarterly, and discharge MDS assessments within required timeframes for 6 of 12 residents reviewed.
F0689: The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in a resident rolling off the bed during incontinence care.
F0812: The facility did not ensure the dish machine reached required sanitization temperatures and did not properly sanitize dishes using the 3-compartment sink, potentially affecting all residents.
Report Facts
Residents sampled: 12
Residents cited for late MDS assessments: 8
Residents cited for late quarterly MDS assessments: 2
Residents cited for late MDS transmission: 6
Residents sampled for fall supervision: 4
Residents cited for inadequate supervision: 1
Residents sampled for food safety: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator-C | MDS Coordinator | Named in relation to late and incomplete MDS assessments |
| CNA-N | Certified Nursing Assistant | Named in relation to resident fall due to improper assistance |
| Director of Nursing (DON)-B | Director of Nursing | Provided statements regarding fall incident and staff re-education |
| Director of Nutritional Services (DNS)-H | Director of Nutritional Services | Provided information and observations regarding dish machine sanitization issues |
| Maintenance/Repair Technician (MRT)-J | Maintenance/Repair Technician | Observed running dish machine and commented on temperature issues |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged neglect and abuse, and concerns about resident care including failure to report allegations timely and inadequate care related to range of motion exercises and fall prevention.
Complaint Details
The complaint involved an allegation of neglect reported by a resident and spouse regarding delayed assistance and perceived abuse. The facility delayed reporting the allegation to the State Survey Agency beyond the required timeframe. The investigation also included concerns about inadequate care for range of motion exercises and insufficient fall prevention and investigation practices for residents.
Findings
The facility failed to timely report an allegation of neglect to the State Survey Agency. The facility did not ensure appropriate treatment and documentation for a resident's range of motion exercises. Additionally, the facility did not provide adequate supervision and fall prevention interventions for another resident, with multiple falls not thoroughly investigated and care plans not consistently updated.
Deficiencies (3)
F0609: The facility did not timely report an allegation of neglect to the State Survey Agency within the required timeframe.
F0688: The facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline, and failed to document completion of prescribed stretching/ROM exercises.
F0689: The facility did not ensure adequate supervision and assistive devices to prevent accidents for a resident with multiple falls, and failed to thoroughly investigate falls or update care plans with new interventions.
Report Facts
Number of falls: 14
Morse fall scale score: 19
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW-D | Social Worker | Received and handled the grievance and email regarding neglect allegation; responsible for reporting to State Agency. |
| NHA-A | Nursing Home Administrator | Informed about the delayed reporting of neglect allegation and fall concerns. |
| DON-B | Director of Nursing | Interviewed regarding responsibility for ROM exercises and fall prevention. |
| NCM-K | Nurse Care Manager | Discussed fall process and care plan updates for resident R2. |
| CNA-V | Certified Nursing Assistant | Provided care and incontinence care to resident R2; interviewed about care routines. |
| RN-L | Registered Nurse | Explained fall process and care plan revision responsibilities. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 1, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care, including care planning, pressure ulcer care, accident prevention, bed rail use, food safety, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with specific needs, inadequate pressure ulcer care and prevention, insufficient investigation and intervention following resident falls, improper use and documentation of bed rails, unsafe food handling practices, and lack of coordination and documentation of hospice services.
Deficiencies (6)
F 0656: The facility did not develop and implement a complete care plan for resident R59 addressing the use of bed canes and a foley catheter.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for resident R34, including lack of individualized care plan, turning schedule, and consistent wound assessments.
F 0689: The facility did not ensure a safe environment free from accident hazards and failed to adequately investigate and update care plans after two falls from recliner for resident R36.
F 0700: The facility did not obtain physician orders, conduct assessments, or document informed consent for the use of bed assist bars for residents R59 and R1, nor attempt appropriate alternatives prior to installation.
F 0812: The facility failed to ensure food service staff wore required beard restraints and improperly handled ready-to-eat food with contaminated gloves, risking food contamination.
F 0849: The facility did not ensure hospice services were properly coordinated for resident R59, lacking physician certification of terminal illness and a designated liaison between facility and hospice provider.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 4
Residents affected: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook-J | Cook | Observed preparing food without beard hair restraint and improper food handling |
| Server-L | Server | Observed walking in kitchen without beard hair restraint and improper glove use |
| Server-K | Server | Observed handling ready-to-eat food with contaminated gloves |
| Nursing Care Manager NCM-D | Nursing Care Manager | Responsible for completing R59's comprehensive care plans; confirmed missing care plans and orders |
| Director of Nursing DON-B | Director of Nursing | Confirmed missing care plans and orders; acknowledged concerns about falls and hospice coordination |
| Certified Dietary Manager CDM-I | Certified Dietary Manager | Informed surveyor about beard restraint supply and food handling expectations |
| Nursing Home Administrator NHA-A | Nursing Home Administrator | Informed of food safety and fall investigation deficiencies |
| Social Worker SW-C | Social Worker | Did not communicate resident R59's concerns to hospice team |
| Hospice Social Worker HSW-G | Hospice Social Worker | Spoke with social worker about resident R59's concerns and need for care plan discussion |
| Admissions Director AD-F | Admissions Director | Spoke to hospice representative about missing physician certification for R59 |
Inspection Report
Routine
Census: 18
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
Surveyor conducted a standard survey at Congregational Home Inc.
Findings
No deficiencies were identified during the survey. The provider can be issued a regular license once full dues are paid.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Congregational Home, Inc.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 7
Date: Mar 29, 2023
Visit Reason
Routine state inspection survey of Congregational Home, Inc nursing facility to assess compliance with regulatory requirements including care planning, medication management, fall prevention, infection control, and other resident care standards.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans for multiple residents, inadequate fall prevention interventions and follow-up, failure to conduct neurological assessments after unwitnessed falls, lack of monitoring for side effects of psychotropic medications, failure to implement infection control hand hygiene, and an incomplete water management plan for Legionella prevention.
Deficiencies (7)
F 0656: The facility failed to develop and implement comprehensive care plans addressing use of motion sensing alarms, anticoagulant medication, and psychotropic medications for residents R24, R31, R47.
F 0657: The facility failed to develop complete care plans within 7 days of assessment and did not revise antipsychotic medication care plans to include resident-centered interventions for R46 and fall prevention care plans for R48 and R50.
F 0684: The facility failed to provide appropriate treatment and care after unwitnessed falls for residents R50 and R19, including lack of neurological assessments and delayed or absent care plan revisions.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevention for resident R2, including failure to offload heels while in bed and recliner and lack of staff awareness of interventions.
F 0689: The facility failed to ensure adequate supervision and fall prevention for residents R24, R50, R19, R17, R109, and R48, including failure to investigate falls, revise care plans, and evaluate effectiveness of interventions.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and did not monitor side effects or document targeted behaviors for residents R46 and R47.
F 0880: The facility failed to implement an effective infection prevention and control program, including inadequate hand hygiene observed for resident R17 and an incomplete water management plan for Legionella prevention.
Report Facts
Falls: 14
Skin tear size: 4.5
BIMS score: 3
BIMS score: 12
BIMS score: 10
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-G | Certified Nursing Assistant | Observed not changing gloves or performing hand hygiene during perineal care for resident R17 |
| RNUM-D | Registered Nurse Unit Manager | Interviewed regarding fall assessment and care plan revision processes |
| UM-C | Unit Manager | Interviewed regarding care plan updates and fall prevention interventions for resident R24 |
| DON-B | Director of Nursing | Interviewed regarding care plan responsibilities and infection prevention program |
| DPO-H | Director of Plant Operations | Interviewed regarding water management plan and Legionella prevention |
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