Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Congregational Home, Inc.

BROOKFIELD, WI · 66 certified beds · Last Life Safety survey July 31, 2025

CMS Certification Number 525700 · first certified January 2010

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Church related

No change of ownership on CMS record since January 1, 2016, when the records begin.

12
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within WI

12 citations — more than 25% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: September 2026 to November 2026. This facility’s last Life Safety survey was July 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility12WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility12
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
42023-0352024-0532025-07
Citations at each Life Safety survey
Survey dateCitations
March 29, 20234
May 1, 20245
July 31, 20253

Most-cited tags

Most-cited tags at this facility
K-03532K-03212K-01322K-09201K-07121K-03241K-03741K-02211
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-05-01
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22025-07-31
K-0132Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.22024-05-01
K-0920Ensure proper usage of power strips and extension cords.12024-05-01
K-0712Have simulated fire drills held at unexpected times.12023-03-29
K-0324Provide properly protected cooking facilities.12024-05-01
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.12025-07-31
K-0221Provide rooms that can be unlocked from inside without a key.12025-07-31

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Miscellaneous Deficiencies 2
  • Construction Deficiencies 2
  • Gas, Vacuum, and Electrical Systems Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Miscellaneous Deficiencies2
Construction Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 31, 2025 — 3 citations

Citations issued on July 31, 2025
TagWhat the surveyor checksStatus
K-0221Provide rooms that can be unlocked from inside without a key.Deficient, Provider has date of correction (August 18, 2025)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (July 31, 2025)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (August 7, 2025)

May 1, 2024 — 5 citations

Citations issued on May 1, 2024
TagWhat the surveyor checksStatus
K-0132Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.Deficient, Provider has date of correction (May 14, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 16, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 1, 2024)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (May 14, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 1, 2024)

March 29, 2023 — 4 citations

Citations issued on March 29, 2023
TagWhat the surveyor checksStatus
K-0132Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.Deficient, Provider has date of correction (March 31, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (March 31, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 2, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (March 31, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.