Cycle 1
Health 2025-07-31 · Fire 2025-07-31
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Brookfield, WI
Congregational Home, Inc
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
13900 W Burleigh Rd, Brookfield, WI
(262) 781-0550
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
61
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-01-01
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.07
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
4.38
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
6.41
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
5.86
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
6.48
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
802
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0182
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.45
Baseline 17.80% · Performance 19.83% · Measure score 3.45 · Achievement 3.45 · Improvement 0
Healthcare-associated infections
6.87
Baseline 4.32% · Performance 5.78% · Measure score 6.87 · Achievement 6.87 · Improvement 0
Total nurse turnover
5.09
Performance 42.86% · Measure score 5.09 · Achievement 5.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
10
Baseline 5.91 hours · Performance 6.28 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 261 · Observed rate 6.13% · Lower 95% interval 6.78% |
| Discharge to community | 65.31% |
50.57%
14.7 pts better
|
Better than the National Rate · Eligible stays 263 · Observed rate 67.3% · Lower 95% interval 59.38% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.38% |
95.27%
1.9 pts worse
|
Numerator 141 · Denominator 151 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 151 |
| Discharge self-care score | 52% |
53.69%
1.7 pts worse
|
Numerator 65 · Denominator 125 |
| Discharge mobility score | 59.2% |
50.94%
8.3 pts better
|
Numerator 74 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 5.96% |
2.29%
3.7 pts worse
|
Numerator 9 · Denominator 151 · Adjusted rate 5.88% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 2.76% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 0.81% |
8.2%
7.4 pts worse
|
Numerator 2 · Denominator 248 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 251 · Denominator 251 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 80 · Denominator 125 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 99.04% |
96.28%
2.8 pts better
|
Numerator 103 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 37.18% |
25.2%
12 pts better
|
Numerator 29 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.2
1.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.2%
0.4 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.9% · Q3 3.0% · Q4 2.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.9%
1.6 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 4.8% · Q4 4.5% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
16.6%
8.2 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.5% · Q3 4.5% · Q4 4.5% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
16.7%
7 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.3% |
21.1%
7.2 pts worse
|
16.3%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
17.3%
0.7 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.5% · Q3 23.8% · Q4 20.0% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.9% |
2.3%
4.6 pts worse
|
1.0%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 5.7% · Q3 8.8% · Q4 4.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
3.0%
1.5 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 2.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
25.5%
6.3 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 34.0% · Q3 19.5% · Q4 40.8% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.5%
1.8 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.6% · Q3 3.4% · Q4 2.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
86.8%
12.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
15.0%
2.8 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 10.2% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 2.3% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
82.2%
14.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
22.7%
0.9 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 18.0% · Expected 18.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-29 · Fire 2023-03-29
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-07-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-05-01
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-05-01
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-01
F · Potential for more than minimal harm
2023-03-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-29
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-03-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-03-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-14
E · Potential for more than minimal harm
2025-07-31
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-31
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-31
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-02-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-02-05
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-02-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-23
G · Actual harm
2024-05-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-05-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-05-01
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-05-01
F849 · Administration Deficiencies
Health
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.
Corrected 2024-05-02
F · Potential for more than minimal harm
2023-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-04
E · Potential for more than minimal harm
2023-03-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-04
E · Potential for more than minimal harm
2023-03-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-04
D · Potential for more than minimal harm
2023-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-04
D · Potential for more than minimal harm
2023-03-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-03-29
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-04-04
Penalties and ownership
What sits behind the stars
$0
2023-03-29
Payment Denial
Payment Denial · denial start 2023-05-27 · 6 days
6 day denial
Ownership
Baird Trust Company
Operational/Managerial Control · Organization
Berg, Tina
Operational/Managerial Control · Individual
Boyd, Mahlon
Corporate Director · Individual
Collis, Harry
Corporate Director · Individual
Crawford, Carrie
Operational/Managerial Control · Individual
Cummings, William
Corporate Director · Individual
Ford, Felicia
Operational/Managerial Control · Individual
Greenfield Rehabilitation Agency, Inc
Operational/Managerial Control · Organization
Griffith, John
Corporate Director · Individual
Guszkowski, Eugene
Corporate Director · Individual
Harmon, Keith
Corporate Director · Individual
Harris, James
Corporate Director · Individual
Henry, Peter
Corporate Director · Individual
Jefferson, Laronda
Operational/Managerial Control · Individual
Kehoss, Anmarie
Operational/Managerial Control · Individual
Krauss, Angela
Operational/Managerial Control · Individual
Lamonte, Stephen
Operational/Managerial Control · Individual
Mauer, Lisa
Corporate Director · Individual
Messnick, Eileen
Corporate Director · Individual
Osell, Gina
Operational/Managerial Control · Individual
Russ, Steven
Corporate Director · Individual
Schloemer, Nathan
Corporate Director · Individual
Schmitt, Ellen
Operational/Managerial Control · Individual
Servais, Patricia
Operational/Managerial Control · Individual
Servais, Patricia
Corporate Officer · Individual
Solakian, Catherine
Operational/Managerial Control · Individual
Sprtel, Kristine
Operational/Managerial Control · Individual
Sprtel, Kristine
Corporate Officer · Individual
Stock, Thomas
Corporate Director · Individual
York, Charles
Corporate Director · Individual
Zovi, Maurice
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Anne's Salvatorian Campus
Milwaukee, WI
2-star overall rating with 1-star inspections with $326,060 in total fines with 26 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Luther Manor
Milwaukee, WI
1-star overall rating with 1-star inspections with $170,666 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
St Camillus Health Center
Wauwatosa, WI
3-star overall rating with 2-star inspections with $90,430 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out