Congregational Home: Fall Investigation Failures WI
BROOKFIELD, WI - An inspection at Congregational Home revealed significant deficiencies in fall prevention protocols after a resident with severe dementia experienced 14 documented falls over a seven-month period without proper investigation or consistent implementation of safety measures.
Inadequate Fall Investigation Procedures
The inspection identified systematic failures in the facility's fall investigation process for a resident with severe cognitive impairment who was on hospice care. The resident, who had a Brief Interview Mental Status score of 3 out of 15 indicating severe cognitive impairment, experienced multiple falls from a specialized Broda chair designed for high-risk patients.
Despite facility policies requiring comprehensive post-fall documentation including statements from staff who last saw the resident and witnesses, inspectors found that most fall reports lacked these critical elements. For falls occurring on July 22, July 24, September 11, October 24, November 9, and November 24, 2024, no statements were included regarding who last saw the resident or what the resident was doing prior to the fall.
The facility's own procedures mandate that charge nurses complete detailed forms after any fall, including notes from appropriate staff providing care and witnesses. However, the inspection revealed that these requirements were consistently not met, compromising the ability to identify root causes and prevent future incidents.
Specialized Equipment Safety Protocols Ignored
The resident required use of a Broda chair, a specialized reclining chair designed to prevent falls in high-risk patients. The manufacturer's operating manual specifically states that the chair's seat should be "tilted sufficiently to prevent the resident from sliding or falling forward off the chair."
Despite this clear guidance and multiple falls documented as the resident "sliding out" of the chair, facility staff repeatedly failed to ensure proper positioning. On July 29, 2024, the post-fall report specifically noted that "resident's Broda chair wasn't reclined according to resident's plan of care when resident's fall occurred."
This represented a direct violation of both the manufacturer's safety recommendations and the facility's own care plan requirements. The resident's care plan had been updated after earlier falls to specify that the Broda chair should be "slightly reclined when resident is in Broda chair," yet staff continued to fail in implementing this basic safety measure.
Delayed Implementation of Safety Interventions
The inspection revealed significant delays between identifying necessary safety interventions and their implementation in the resident's care plan. After the resident's fall on July 22, 2024, facility staff recommended ensuring the Broda chair was properly reclined, but this intervention was not added to the fall care plan until July 24 - after another fall had already occurred.
Similar delays occurred with other safety measures. Following a fall on July 24, staff identified that the resident became restless when needing incontinence care changes, but this intervention was not incorporated into the care plan until July 29, five days later.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Congregational Home, Inc. in BROOKFIELD, WI was cited for violations during a health inspection on February 5, 2025.
## Medical Context and Risk Factors Falls in nursing home residents with severe dementia carry significant medical risks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.