Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Congregational Home, Inc. during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident was not assessed completely and in a timely manner upon admission and at the required periodic intervals, as mandated by regulations.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period following assessment, as identified through record review.
Two residents did not have their quarterly MDS assessments completed within the required timeframe. The sole full-time MDS Coordinator was unable to keep up with all assessments due to lack of assistance, prioritizing Medicare MDS assessments and leaving quarterly assessments delayed or incomplete. The issue was acknowledged by facility leadership.
A resident with significant medical needs and a high risk for falls was rolled away from a CNA during incontinence care, contrary to facility policy requiring residents to be rolled toward the caregiver. This action caused the resident to fall from the bed into the space between the bed and the wall. The incident occurred despite clear facility protocols and staff expectations for safe resident handling.
A facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. A resident and their spouse filed a grievance about a care concern, which was later deemed neglectful and abusive by the spouse. The facility's social worker received an email about the allegation during a holiday weekend but did not report it until after the weekend, violating the facility's policy on timely reporting of such incidents.
A resident with Multiple Sclerosis and spasticity did not consistently receive prescribed ROM exercises twice daily, as facility staff failed to document the completion of these exercises. The resident's care plan lacked measurable goals, and some CNAs were hesitant to perform the exercises. The facility's Director of Nursing and Nursing Care Manager acknowledged the lack of documentation and a comprehensive care plan.
A resident with severe cognitive impairment and multiple medical conditions experienced multiple falls due to inadequate supervision and improper use of a Broda chair. The facility failed to thoroughly investigate falls, update care plans promptly, and ensure interventions were consistently implemented, despite the resident's high fall risk.
A resident at high risk for pressure injuries was not provided with an individualized care plan or consistent wound assessments, leading to the development of a deep tissue injury. The facility failed to document refusals of care and did not update the care plan to address the new injury.
The facility failed to ensure food safety and sanitation standards were met. Staff members were observed not wearing required beard hair restraints and handling ready-to-eat food with contaminated gloves, affecting the quality of food service for residents.
A resident with a foley catheter and bed canes did not have an individualized comprehensive care plan addressing these needs. Despite facility policy requiring such plans, the resident's care plan lacked specific interventions. The nursing care manager and director of nursing confirmed the oversight.
A resident experienced two falls from their recliner, and the facility did not thoroughly investigate the falls or update the resident's care plan with new interventions to prevent future falls. The facility's Falls policy and procedure were not followed, and the resident's fall risk admission assessment was incomplete. The Director of Nursing acknowledged the lack of thorough investigation and care plan updates.
The facility failed to document attempts to use appropriate alternatives and did not complete necessary assessments and obtain informed consent before installing bed rails for two residents. The Director of Nursing and Nursing Care Manager confirmed the deficiencies.
A resident admitted on hospice care did not have a physician certification of terminal illness, and the facility failed to designate a liaison between the facility and the hospice provider. The resident expressed frustration about unmet needs, and the hospice binder lacked necessary documentation. Facility staff were unaware of the missing certification and hospice order, leading to ineffective communication and coordination of care.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Complete Timely Resident Assessments
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and then periodically, at least every 12 months, as required. The report notes that the necessary comprehensive assessment was not conducted within the specified timeframes, which constitutes noncompliance with assessment regulations.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. This deficiency was identified based on a review of facility records, which showed that required assessment data were not submitted to the State in the specified timeframe. The report does not provide additional details about specific residents or their medical conditions at the time of the deficiency.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for two of twelve residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment, with the completion date no later than 14 days after the Assessment Reference Date (ARD). For one resident, the quarterly MDS assessment was completed 23 days after the required due date. For another resident, the quarterly MDS assessment was still in progress and not completed by the specified deadline. The MDS Coordinator reported being the only full-time staff member responsible for MDS assessments and stated an inability to keep up with all required assessments due to lack of assistance. The Coordinator indicated that priority was being given to Medicare MDS assessments, resulting in quarterly assessments being delayed. During the Coordinator's absence, a pool nurse was covering the role, and the facility was in the process of training another RN for the position. The issue of late and incomplete MDS assessments was acknowledged by the MDS Coordinator and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Adequate Supervision During Incontinence Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during incontinence care for a resident with multiple medical conditions, including vascular dementia, chronic kidney disease, and a history of falls. The resident was assessed as being at high risk for falls and was dependent on staff for activities of daily living, mobility, and transfers. During the incident, the CNA rolled the resident away from themselves while the bed was positioned next to the wall, contrary to facility policy, which states that residents should be rolled toward the caregiver when only one staff member is assisting. As a result, the resident rolled off the bed and onto the floor, landing in the space between the bed and the wall. The resident did not sustain an injury from the fall. Interviews with multiple CNAs and nursing leadership confirmed that the expectation is to roll residents toward the caregiver during care when only one staff member is present. The CNA involved in the incident did not follow this protocol, and there was uncertainty about whether the bed was properly positioned or if the brakes were locked at the time of the incident. The facility's policy and staff interviews consistently indicated that the correct procedure was not followed, leading to the resident's fall.
Delayed Reporting of Neglect Allegation
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. A resident and their spouse filed a grievance with the facility's social worker regarding a care concern that occurred on a specific date. The grievance was investigated, and the results were communicated to the resident and their spouse. However, during the Thanksgiving holiday weekend, the spouse sent an email to the social worker, indicating that they believed the incident was neglectful and abusive. The facility did not report this allegation to the State Agency until after the holiday weekend, which was beyond the required reporting timeframe. The facility's policy mandates that allegations of abuse, neglect, exploitation, or mistreatment must be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. Despite this policy, the facility did not have a process in place to address potential abuse or neglect concerns during non-working hours, such as weekends or holidays. The social worker, who was responsible for receiving and acting on such reports, did not check emails during the holiday weekend, leading to a delay in reporting the allegation to the State Agency. The resident involved in the incident had a medical history that included Multiple Sclerosis, Demyelinating Disease of the Central Nervous System, and Spastic Hemiplegia. The resident's cognition was intact, and they were responsible for themselves. The delay in reporting the allegation of neglect was identified during a surveyor's investigation, which included interviews with the resident, their spouse, and facility staff. The facility's failure to report the allegation in a timely manner was a deficiency noted by the surveyor.
Failure to Ensure Consistent ROM Exercises for Resident with Spasticity
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their condition. The resident, who has a diagnosis of Multiple Sclerosis with spasticity, reported to the surveyor that they do not always receive assistance from facility staff to complete their prescribed stretching and range of motion (ROM) exercises twice daily, as indicated in their Certified Nursing Assistant (CNA) Kardex. The facility staff did not document when these exercises were completed, and the resident's care plan lacked measurable goals and interventions related to their spasticity and ROM. The resident's medical records and interviews with facility staff revealed inconsistencies in the implementation of the prescribed ROM exercises. Although the resident's CNA Kardex included detailed instructions for morning and afternoon stretches, there was no documentation in the electronic medical record to confirm that these exercises were being performed. Interviews with CNAs and the Nursing Care Manager indicated that while some staff were aware of the exercise requirements, there was no formal documentation process in place to verify completion. Additionally, some CNAs expressed reluctance or fear in performing the exercises, which may have contributed to the inconsistency in care. The facility's Director of Nursing and Nursing Care Manager acknowledged the lack of documentation and the absence of a comprehensive care plan with measurable goals for the resident's ROM exercises. Despite the resident's ability to communicate their needs and report any lapses in care, the facility did not have a restorative program in place to ensure consistent implementation of the prescribed exercises. This deficiency highlights a gap in the facility's processes for monitoring and documenting the care provided to residents with specific therapeutic needs.
Inadequate Supervision and Care Plan Updates Lead to Multiple Falls
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices to prevent falls for a resident with severe cognitive impairment and multiple medical conditions, including dementia, anxiety disorder, and epilepsy. The resident, who was non-ambulatory and required a Broda chair for safety, experienced multiple falls that were not thoroughly investigated. The facility's policy required comprehensive post-fall assessments and updates to the care plan, but these were not consistently followed. The resident's falls were often unwitnessed, and there was a lack of documentation regarding the last known activities of the resident or whether prior interventions were in place. The Broda chair, which was supposed to be slightly reclined to prevent sliding, was not always positioned correctly, contributing to the falls. Additionally, the care plan was not promptly updated with new interventions following each fall, and staff statements were frequently missing from post-fall reports. Despite the resident's high risk for falls, as indicated by a Morse fall scale score and a history of previous falls, the facility did not ensure that interventions were consistently implemented or that the care plan was revised in a timely manner. The interdisciplinary team did not adequately follow up on incidents, and there was a lack of communication and documentation regarding the resident's care and supervision needs.
Failure to Provide Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident at high risk for pressure injuries was comprehensively assessed and provided with an individualized care plan to promote healing, prevent infection, and prevent new pressure injuries. The resident, who was admitted with a femur fracture and chronic kidney disease, had a Braden score indicating high risk for pressure injuries. Despite this, the facility did not initiate a turning or repositioning schedule for the resident, who subsequently developed a suspected deep tissue injury to the right heel. The care plan was not updated to address this new injury, and weekly wound assessments were not consistently conducted as required by the facility's policy. Observations by the surveyor noted the resident sitting in a recliner chair with their feet resting directly against the footrest, which could contribute to pressure injury development. The resident's medical records showed consistent measurements of the deep tissue injury over several months, indicating a lack of progress in healing. The facility's Director of Nursing (DON) acknowledged that the unit manager responsible for the resident's care had been terminated for not performing their duties, including weekly wound assessments. Interviews with the DON revealed that the resident often refused repositioning and the use of offloading heel boots, but there was no documentation of these refusals or discussions of the risks versus benefits with the resident or their representative. The Nursing Home Administrator (NHA) and DON were unable to provide additional information or justification for the lack of a comprehensive care plan and consistent wound assessments for the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, Cook-J and Server-L were observed multiple times without wearing beard hair restraints while preparing and handling food in the kitchen. Despite the facility's policy requiring hair restraints to prevent hair from contacting exposed food, both staff members were seen without the necessary beard hair restraints on several occasions. The Certified Dietary Manager (CDM) acknowledged the issue and mentioned that they were waiting for an order of beard restraints, substituting them with hair nets in the meantime. However, the expectation was for staff to always have hair and beards completely covered, which was not adhered to during the observations. Additionally, Server-K was observed handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. This occurred multiple times, including touching the counter, their pants, and a metal cart before handling food meant for residents. The facility's policy states that gloves should be changed between tasks with proper hand washing, but this was not followed. The CDM confirmed that the expectation was for gloves to be changed between tasks, but this was not practiced by Server-K during the surveyor's observations.
Lack of Comprehensive Care Plan for Resident
Penalty
Summary
The facility did not ensure that a resident had an individualized comprehensive plan of care. The resident, who has a foley catheter and uses bed canes, did not have a care plan with specific interventions to address these needs. The facility's policy requires the interdisciplinary team to develop and implement a person-centered comprehensive care plan based on the resident's medical, physical, mental, and psychosocial needs. However, the surveyor found that the resident's care plan did not include interventions for the foley catheter or bed canes, despite these being documented in the resident's baseline care plan. The resident was admitted with diagnoses including malignant neoplasm of the bladder, chronic kidney disease stage 3, anxiety disorder, and restlessness and agitation. The resident is cognitively intact and requires various levels of assistance for daily activities. During the survey, the nursing care manager and the director of nursing confirmed that there were no care plans in place for the resident's foley catheter and bed canes, acknowledging that such care plans should have been developed and implemented. No further information was provided as to why the care plans were missing.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for a resident reviewed for falls. The resident experienced two falls from their recliner on separate occasions. The falls were not thoroughly investigated, and the resident's plan of care was not updated to prevent future falls with person-centered interventions. The facility's Falls policy and procedure were not followed, as the resident's fall risk admission assessment did not determine and document the level of fall risk, and the Morse Fall Scale was not completed as required. The resident's care plan, initiated on admission, included several interventions to prevent falls, such as ensuring the call light was within reach, wearing appropriate footwear, and maintaining a safe environment. However, after the resident's falls, the care plan was not updated with new interventions. The incident notes for both falls lacked documentation on whether the call light was on at the time of the falls or if there was any device in the recliner. Additionally, there were no Interdisciplinary Team (IDT) meeting notes to review the falls. The Director of Nursing acknowledged that a thorough investigation was not completed for both falls and that there were no care plan updates as a result of each fall from the recliner. The facility did not ensure that the resident had updated interventions in place to prevent accidents after experiencing two falls from the recliner. The IDT met to review the falls and implemented a new intervention, but no additional information was provided as to why the facility did not ensure updated interventions after the falls.
Failure to Document Alternatives and Assessments for Bed Rails
Penalty
Summary
The facility failed to provide evidence that it attempted appropriate alternatives before installing bed rails for two residents, R59 and R1. For R59, there was no documentation of a physician's order or a care plan for the use of bed canes. Additionally, the facility did not document any attempts to use appropriate alternatives before installing the bed assist bars. R59, who is cognitively intact, confirmed using the repositioning bars to pull himself up in bed, but the necessary assessments and documentation were missing. For R1, the facility did not update the assessment quarterly to document the risks and benefits of bed rails, nor did it obtain informed consent before the installation of half bed rails. R1's comprehensive care plan and physician orders were outdated and did not reflect the current use of half side rails. The facility also failed to document any attempts to use appropriate alternatives before installing the bed assist bars for R1. R1, who has moderately impaired decision-making skills, confirmed using the half siderails to boost himself up in bed. The facility's policy requires a comprehensive assessment, informed consent, and attempts to use appropriate alternatives before installing bed assist bars. However, these steps were not followed for R59 and R1, leading to deficiencies in the care provided. The Director of Nursing and Nursing Care Manager confirmed the lack of necessary documentation and assessments for both residents.
Failure to Ensure Coordinated Hospice Services
Penalty
Summary
The facility failed to ensure coordinated hospice services for a resident (R59) who was admitted on hospice care. The resident did not have a physician certification of terminal illness, and the facility did not designate a specific individual from the interdisciplinary team to act as a liaison between the facility and the hospice provider. The facility's hospice services policy and procedure require a coordinated plan of care, including a physician order for hospice services and a designated liaison, which were not in place for R59. Additionally, the resident's current physician orders did not include an order for hospice services, and the hospice binder lacked the necessary physician certification of terminal illness. During the survey, the resident expressed frustration and agitation about unmet needs, such as a non-working razor and hearing aids. The surveyor found that the hospice binder contained outdated progress notes and lacked the physician certification of terminal illness. The facility staff, including the Licensed Practical Nurse (LPN) and Social Worker (SW), were unaware of the location of the hospice binder and had not communicated the resident's concerns to the hospice team. The Director of Nursing (DON) and Admissions Director (AD) were also unaware of the missing physician certification and hospice order. The surveyor's interviews with facility staff revealed a lack of communication and coordination between the facility and the hospice provider. The Hospice Social Worker (HSW) confirmed that the resident's concerns had not been communicated, and a new plan of care was needed. The facility had not designated a specific individual to act as a liaison, and the physician certification of terminal illness was not attached to the hospice comprehensive care plan upon the resident's admission. The facility's failure to ensure proper documentation and communication resulted in the resident's care concerns not being addressed effectively.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brookfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Anne's Salvatorian Campus | 3 mi | ★★★★★ | 2 | 0 |
| Luther Manor | 3.4 mi | ★★★★★ | 17 | 0 |
| St Camillus Health Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Franciscan Woods | 3.7 mi | ★★★★★ | 22 | 0 |
| Aria Of Brookfield | 3.8 mi | ★★★★★ | 39 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.