01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-31 | 5 | 2025-07-31 | 3 |
| Cycle 2 | 2024-05-01 | 9 | 2024-05-01 | 5 |
| Cycle 3 | 2023-03-29 | 7 | 2023-03-29 | 4 |
CMS CCN 5257002026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Congregational Home, Inc.
13900 W Burleigh Rd · Brookfield, WI 53005 · Waukesha County
Certified beds66CMS provider file
Recent citation rows33current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
33 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-07-31 · HEALTHF0636Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-31 · HEALTHF0638Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-31 · HEALTHF0640Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-31 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-31 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-08-142025-07-31 · FIREK0221Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Provide rooms that can be unlocked from inside without a key.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-31 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-07-312025-07-31 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2025-08-072025-02-05 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-02-06 · complaint2025-02-05 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2025-02-23 · complaint2025-02-05 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-02-23 · complaint2024-05-01 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-05-022024-05-01 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-05-022024-05-01 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-05-01 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Correction field: Deficient, Provider has date of correction · 2024-05-022024-05-01 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-05-022024-05-01 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Correction field: Deficient, Provider has date of correction · 2024-05-022024-05-01 · FIREK0132Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Correction field: Deficient, Provider has date of correction · 2024-05-142024-05-01 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-05-162024-05-01 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-05-012024-05-01 · FIREK0711Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2024-05-142024-05-01 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2024-05-012023-03-29 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-04-042023-03-29 · HEALTHF0657Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2023-04-0403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BOYD, MAHLONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2023
- COLLIS, HARRYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2021
- CUMMINGS, WILLIAMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2020
- GRIFFITH, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2020
- GUSZKOWSKI, EUGENEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2020
- HARMON, KEITHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2023
- HARRIS, JAMESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2024
- HENRY, PETERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2021
- MAUER, LISAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2019
- MESSNICK, EILEENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2019
- RUSS, STEVENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2021
- SCHLOEMER, NATHANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2021
- STOCK, THOMASIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2023
- YORK, CHARLESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2022
- BOYD, MAHLONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2023
- COLLIS, HARRYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2021
- CUMMINGS, WILLIAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2020
- GRIFFITH, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours6.36per resident day
RN hours1.18per resident day
Weekend nurse hours5.87per resident day
Staff turnover46.4%CMS reported field