Compassionate Adult Family Home

Penalties

• — DQA enforcement letter

Inspection findings

Nursing homes: CMS Care Compare inspections (last three cycles), penalties and ownership. Assisted living: DHS directory data and statements of deficiencies DHS has posted since October 2026; older survey documents are on the DQA Provider Search. An absence of findings here does not mean a clean record.

1. Jul 15, 2026 DQA survey · 12 findings
   • Severity not stated

     M 134 88.03(5)(e)1 SIGNIFICANT CHANGE TO THE

     Based on record review and interview, the licensee did not report to the Department a significant change in resident status for 1 of 1 resident. One of 1 resident eloped and was returned to the facility by law enforcement. These incidents were not reported to the Department. Resident 2 eloped 2 times from the facility that were not self-reported to the Bureau. Resident 2 eloped 2 times from the sister facility that were not self-reported to the Bureau. Findings include: On 07/13/2026, Surveyors reviewed police reports from the West Bend Police Department, Cedarburg Police Department and Mequon Police Department. - West Bend Police Reports show Resident 2 eloped on 05/13/2026 and 06/10/2026. - Cedarburg Police Reports show Resident 2 eloped on 06/14/2026. - Mequon Police Reports show Resident 2 eloped on 05/23/2026. On 07/13/2026, Surveyors reviewed the facility folder. There were no self-reports filed for Resident 2's elopements on 05/13/2026 and 06/10/2026 reported to the West Bend Police Department, 6/14/2026 reported to the Cedarburg Police Department and 05/23/2026 reported to the Mequon Police Department. On 07/13/2026 at 10:00 AM, Surveyors interviewed Caregiver D. Caregiver

     Statement of deficiencies (PDF)

   • Severity not stated

     M 216 88.04(2)(a) RESPONSIBILITIES

     Based on record review and interview, the licensee did not ensure the provider, and its operation complied with all laws governing an Adult Family Home (AFH). Findings include: The facility was licensed on 05/27/2025 to provide care for up to 4 residents who may be emotionally disturbed/mental illness, physically disabled, pregnant women/counseling, advanced age, developmentally disabled, alcohol/drug dependent, traumatic brain injury, correctional clients, terminally ill and/or irreversible dementia/Alzheimer's. On 07/13/2026, at 10:00 AM, Surveyors arrived at the facility to investigate 1 complaint. Caregiver D was working in the facility and left Surveyors in. Licensee A met Surveyors on-site at 11:00 AM. Caregiver D was working alone in the home with 3 residents and had a barred offense. During the complaint investigation and verification visit, six deficiencies were identified, including:

     Statement of deficiencies (PDF)

   • Severity not stated

     M 230 88.04(2)(f) CONDITION WHICH REPRESENTS

     Based on observation, record review and interview, the licensee permitted the existence or continuation of conditions in the home which placed the health, safety and welfare of residents at substantial risk of harm for Resident 1. Resident 1 required supervision. Resident 1 was not supervised in the kitchen resulting in police contact due to smoke alarms sounding. Findings include: The facility is licensed to provide care for up to 4 ambulatory residents who may be emotionally disturbed/mental illness, physically disabled, pregnant women/counseling, advanced age, developmentally disabled, alcohol/drug dependent, traumatic brain injury, correctional clients, terminally ill and/or irreversible dementia/Alzheimer's. On 07/13/2026 at 11:00 AM, Surveyors requested Resident 1's record from Licensee A. Police Reports On 07/13/2026, Surveyors reviewed the police report dated 04/22/2026 from the West Bend Police Department. The report noted the following: 04/22/2026 at 7:58 AM: Resident 1 burned breakfast food on the top of the oven causing the homes fire alarm to sound. Record Review On 07/13/2026, Surveyors reviewed Resident 1's record. The record reflected Resident 1 was admitted on 12/1

     Statement of deficiencies (PDF)

   • Severity not stated

     M 262 88.05(2)(a) DIFFICULTY WALKING

     Based on record review and interview, the provider did not ensure the home was ramped to grade when a resident required the use of a walker to ambulate. Findings Include: The facility was licensed on 05/27/2025 to provide care for up to 4 ambulatory residents who may be emotionally disturbed/mental illness, physically disabled, pregnant women/counseling, advanced age, developmentally disabled, alcohol/drug dependent, traumatic brain injury, correctional clients, terminally ill and/or irreversible dementia/Alzheimer's. Record Review On 07/13/2026, Surveyors reviewed Resident 3's record. The record reflected Resident 3 was admitted to the facility 06/27/2026. Due to being within 30 days of admission, Resident 3 did not have a completed assessment or ISP. Observation On 07/13/2026, at approximately 9:53AM, Surveyors observed the front entrance/exit of the home was not ramped to grade. Surveyors observed a step led to the porch and another step to get inside. Interview with Resident 3 On 07/13/2026, at 10:06AM, Surveyor interviewed Resident 3. Surveyor observed Resident 3 was sitting on his/her bed and had a walker sitting next to his/her bed. Resident 3 identified s/he uses the walker

     Statement of deficiencies (PDF)

   • Severity not stated

     M 424 88.06(3)(f) REVIEW OF ISP

     Based on record review and interview, the provider did not ensure the individual service plan (ISP) was updated whenever the residents' needs changed for Resident 2. Findings include: On 06/17/2026, the department received a complaint alleging concerns with supervision of residents. Police Reports from On 07/13/2026, Surveyor reviewed police reports that documented Resident 2's elopements. The reports showed Resident 2 eloped from the facility on the following days: 05/13/2026 at 7:50PM: Staff reported to the police department Resident 2 left the home. Police found Resident 2 and returned him/her to the home. 06/10/2026 at 8:13PM: Licensee A called to report resident left the home. The police found Resident 2 and returned him/her to the home. Interview with Licensee A On 07/13/2026, at 10:42AM, Surveyors interviewed Licensee A about Resident 2. Licensee A reported Resident 2 has a history of calling the police or trying to leave the house when s/he is out of cigarettes or wants to go home with his/her family. Licensee A stated Resident 2 should always be supervised and staff should follow him/her when s/he leaves the home. Licensee A explained Resident 2's cigarettes are locked in

     Statement of deficiencies (PDF)

   • Severity not stated

     N 0134 DHS 88.06(5)(e)1 Significant Change To

     Resident Based on record review and interview, the licensee did not report to the Department a significant change in resident status for 1 of 1 resident. One of 1 resident eloped and was returned to the facility by law enforcement. These incidents were not reported to the Department. -Resident 2 eloped 2 times that were not self-reported to the Bureau.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 0216 DHS 88.04(2)(a) Responsibilities

     Based on record review and interview, the licensee did not ensure the provider, and its operation complied with all laws governing an Adult Family Home (AFH).

     Statement of deficiencies (PDF)

   • Severity not stated

     N 0230 DHS 88.04(2)(f) Condition Which

     Represents Risk or Harm Based on observation, record review and interview, the licensee permitted the existence or continuation of conditions in the home which placed the health, safety and welfare of residents at substantial risk of harm for Resident 1, Resident 2 and Resident 3. -Resident 1 required supervision. Resident 1 was not supervised in the kitchen resulting in police contact due to smoke alarms sounding.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 0262 DHS 88.05(2)(a) Difficulty Walking

     Based on record review and interview, the provider did not ensure the home was ramped to grade when a resident required the use of a walker to ambulate.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 0424 DHS 88.06(3)(f) Review of ISP

     Based on record review and interview, the provider did not ensure the individual service plan (ISP) was updated whenever the residents' needs changed for Resident 2.

     Statement of deficiencies (PDF)

   • Severity not stated

     Z 0023 DHS 50.65(4m)(b) Caregiver Hiring and

     Contracting Process Based on record review and interview, the facility permitted Caregiver D to work in the home when Caregiver D had a barred offense. - Caregiver D was charged with aggravated battery 940.19(6) Cross Reference Z0023 DHS 50.065(4m)(b) Caregiver Hiring and Contracting Process Cross Reference N0134 DHS 88.03(5)(e)(1) Significant Change To The Resident Cross Reference N0216 DHS 88.04(2)(a) Responsibilities Cross Reference N0230 DHS 88.04(2)(f) Condition Which Represents Risk or Harm Cross Reference N0262 DHS 88.05(2)(a) Difficulty Walking Cross Reference N0424 DHS 88.06(3)(f) Review of ISP

     Statement of deficiencies (PDF)

   • Severity not stated

     Z 023 50.065(4m) (b) intro CAREGIVER HIRING AND

     Based on record review and interview, the provider permitted Caregiver B to work in the home when Caregiver B had a barred offense. - Caregiver B was charged with aggravated battery 940.19(6) Findings include: On 07/13/2026 at 10:00 AM, Surveyors entered the home with Caregiver D working. Caregiver D was the only staff present with 3 residents. At 11:00 AM Licensee A arrived at the facility and provided Caregiver D's employee record. Caregiver D's record identified the following: -Caregiver D had a hire date of 04/27/2026 -Caregiver D's Department of Justice, dated 04/27/2026, noted that Caregiver D was charged with aggravated battery 940.19(6), on 12/06/2018 (the county case document showed Caregiver B was guilty of Felony H 940.19(6)) On 07/13/2026 at 11:45 AM, Surveyors interviewed Caregiver B. Caregiver B stated s/he started at the Mequon location, but when the census was low, Licensee A moved him/her to the West Bend location. Caregiver B confirmed s/he works full-time between the 2 houses. Caregiver B acknowledged the aggravated battery happened years ago. On 07/13/2026 at 12:00 PM, Surveyors interviewed Licensee A. Licensee A acknowledged s/he does not always look at caregiv

     Statement of deficiencies (PDF)