Compassionate Adult Family Home LLC

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 · 16 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 6 times that were not self-reported to the Bureau. This is a repeat deficiency. See statement of deficiency (SOD) VOSA13, 10/22/2025. Findings include: On 05/21/2026 and 06/17/2026 the Bureau received complaints alleging resident elopements. On 07/13/2026, Surveyors reviewed police reports from the Cedarburg Police Department and the Mequon Police Department. * Cedarburg Police Reports show Resident 2 eloped on 04/13/2026, 05/13/2026, 06/06/2026, 06/14/2026, 06/15/2026 and 06/17/2026. On 07/13/2026, Surveyors reviewed the facility folder. There were no self-reports filed for Resident 2's elopements on 04/13/2026, 05/13/2026, 06/06/2026, 06/14/2026, 06/15/2026 and 06/17/2026. Surveyors observed a self-report filed on 05/31/2026, when Resident 2 was left unattended at home. On 07/13/2026 at 7:20 AM, Surveyors interviewed Caregiver C. Caregiver C confirmed Resident 2 had both eloped from the faci

     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 is licensed 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 7:00 AM, Surveyors arrived at the facility to investigate 3 complaints. Surveyors rang the doorbell and knocked with no answer. Surveyors observed all windows in the house and garage to be covered. Surveyors called Licensee A's phone number and left a message. At 7:42 AM, Licensee A returned call to Surveyors. At 8:05 AM Licensee A arrived at the facility. Licensee A stated there was not anyone currently home. Licensee A stated Resident 2 had moved out and Resident 1 left with family yesterday, 07/12/2026, and s/he had not returned to the facility. Licensee A was unable to provide Surveyors with Resident 1's family name or contact number, as s/he did not have.

     Statement of deficiencies (PDF)

   • Severity not stated

     M 218 88.04(2)(b) AWAKE STAFF FOR CONTINUOUS

     Based on record review and interview, the provider did not ensure there was an awake staff at all times when a resident required continuous care for Resident 1. Resident 1 required 24/7 continuous staffing. Licensee A reported s/he worked 24 hours a day for approximately 1 week. Licensee A could not verify how awake staffing was maintained during that time. Findings Include: On 05/21/2026 and 06/17/2026 the Bureau received complaints alleging inadequate supervision. Interview with Licensee A On 07/13/2026, at 9:01 AM, Surveyors interviewed Licensee A regarding staffing at the adult family home. Licensee A advised since Resident 1 is the only resident at the home, there are only 2 caregivers, Licensee A and Caregiver D. Licensee A reported Caregiver D was on vacation the previous week and Licensee A was working 24 hours a day with Resident 1. Surveyors inquired if Resident 1 could be unsupervised during sleep hours as it would be difficult to work 24 hours a day for a week. Licensee A responded by explaining Resident 1 no longer required a 1:1 level of supervision. Licensee A again confirmed s/he was the only caregiver working with Resident 1 the previous week. Additionally, License

     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 and Resident 2. Resident 1 was protectively placed and had guardian. Resident 1's member-centered plan stated s/he required 24-hour supervision, including overnights. Resident 1 was not present during the survey on 07/13/2026. Licensee A advised Resident 1 was with his/her family on 07/12/2026 and decided to spend the night. Resident 1 did not have his/her medications and missed the evening doses on 07/12/2026 and morning doses on 07/13/2026. Licensee A had no address or phone contact information for the family member. Resident 1's corporate guardian confirmed s/he was not aware of the unsupervised away from home/overnight visit. The corporate guardian stated this was not discussed or approved. Licensee A advised s/he worked at the home for 24 hours a day the last week with Resident 1. Licensee A could not verify how awake staffing was provided to Resident 1 during the timeframe. Resident 2 was protectively placed and had a guardian. Resident 2's behavior

     Statement of deficiencies (PDF)

   • Severity not stated

     M 276 88.05(3)(a) Homelike Environment

     Based on observation and interview, the provider did not ensure the adult family home was well-maintained and provided a homelike environment for 1 of 1 resident. Findings include: On 07/13/2026 at 8:05 AM, Surveyors entered with Licensee A. Surveyors observed garage windows covered with wood and all windows in the house covered with fabric. Surveyors observed the refrigerator splattered with food-like substances and splatters of red food-like substance on the walls and ceiling. At approximately 8:30 AM, Surveyors observed black mold like substance on the wall in the basement laundry area and dryer vent area to be covered with lint-like substance. Surveyors observed the hallway floor by the back door to be sticky. On 07/13/2026 at 8:30 AM, Licensee A acknowledged the wood covering the garage windows and stated the landlord must have placed the wood over the windows. Licensee A stated s/he had told staff to clean the basement this past weekend and was surprised staff had not cleaned. Licensee A stated s/he would look at the concerns identified. On 07/13/2026 at 12:51 PM, Surveyors interviewed Landlord E. Landlord E stated s/he had not been at this house and had not placed wood over

     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 1 and Resident 2. Resident 1's ISP was not updated to reflect a change in the level of supervision needed. Resident 2's ISP was not updated to reflect elopement interventions. Resident 2 eloped from the facility 6 times. Findings Include: On 05/21/2026 and 06/17/2026, the department received complaints concerning supervision of residents. RESIDENT 1 Assessment ON 07/13/2026, Surveyor reviewed Resident 1's assessment dated 04/08/2024. The assessment identified Resident 1 required "24-hour direct supervision." Member Centered Plan 05/17/2025 On 07/13/2026, Surveyor reviewed Resident 1's managed care organizations member centered plan (MCP), dated 05/17/2025. The MCP noted Resident 1 required "1:1 staff 24 hours a day" and "line of sight only when potentially hazardous items are being utilized." Member Centered Plan 06/01/2026 On 07/13/2026, Surveyor reviewed Resident 1's most current MCP dated 06/01/2026. The MCP noted Resident 1 required "24/7 care and supervision ...overnight care/supervision ..." Individual Support Plan

     Statement of deficiencies (PDF)

   • Severity not stated

     M 550 88.10(3)(b) Privacy

     Based on observation and interview, the provider did not ensure 2 of 2 residents had privacy in their own home. Findings Include: The facility is licensed 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 7:20 AM, Surveyors interviewed Caregiver C. Caregiver C confirmed Person G stays at this home on the weekends, and staff drops him/her off during the week when there are no caregivers at the other house. Caregiver C confirmed Resident 2 and Person G had both eloped from the facility and the police were called. On 07/13/2026 at 8:10 AM, Surveyors entered the home and interviewed Licensee A. Licensee A stated Person G did not reside at this location and was not at this house. Licensee A stated the only time Person G would be at this location is if Person G was with Licensee A and s/he needed to stop at the house. Licensee A stated Person G was never at this location without him/her. Surveyors shared police reports iden

     Statement of deficiencies (PDF)

   • Severity not stated

     M 582 88.10(3)(q) Medications

     Based on record review, interview and observation, the provider did not ensure residents received medications as they were prescribed for Resident 1. Resident 1 was protectively placed and had a corporate guardian. Resident 1 stayed overnight at a family member's house and the Licensee did not ensure Resident 1 had his/her medications. Findings Include: Interview with Licensee A On 07/13/2026 at 8:05 AM, Surveyors entered the home to conduct three complaint investigations. Licensee A advised Resident 1 was out with family. Licensee A reported Resident 1 went with his/her family member yesterday (07/12/2026). Licensee A explained Resident 1 did not return home because s/he wanted to spend the night with the family member. Licensee A confirmed Resident 1 did not take any of his/her medications and missed his/her evening medications for 07/12/2026 and morning medications for 07/13/2026. Member Centered Plan On 07/13/2026, Surveyor reviewed Resident 1's most current MCP dated 06/01/2026. The MCP noted the following: Resident 1 required "full assist" medication administration due to cognition. Individual Support Plan On 07/13/2026, Surveyors reviewed Resident 1's individual support plan

     Statement of deficiencies (PDF)

   • Severity not stated

     N 134 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 6 times that were not self-reported to the Bureau. This is a repeat deficiency. See statement of deficiency (SOD) VOSA13, 10/22/2025.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 216 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 218 DHS 88.04(2)(b) Awake Staff For

     Continuous Care Based on record review and interview, the provider did not ensure there was an awake staff at all times when a resident required continuous care for Resident 1. - Resident 1 required 24/7 continuous staffing. Licensee A reported s/he worked 24 hours a day for approximately 1 week. Licensee A could not verify how awake staffing was maintained during that time.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 230 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 and Resident 2. Resident 1 was protectively placed and had guardian. Resident 1's member-centered plan stated s/he required 24-hour supervision, including overnights. Resident 1 was not present during the survey on 07/13/2026. Licensee A advised Resident 1 was with his/her family on 07/12/2026 and decided to spend the night. Resident 1 did not have his/her medications and missed the evening doses on 07/12/2026 and morning doses on 07/13/2026. Licensee A had no address or phone contact information for the family member. Resident 1's corporate guardian confirmed s/he was not aware of the unsupervised away from home/overnight visit. The corporate guardian stated this was not discussed or approved. Licensee A advised s/he worked at the home for 24 hours a day the last week with Resident 1. Licensee A could not verify how awake staffing was provided to Resident 1 during the timeframe. Resident 2 was protectively placed and had a guardian

     Statement of deficiencies (PDF)

   • Severity not stated

     N 276 DHS 88.05(3)(a) Home Like Environment

     Based on observation and interview, the provider did not ensure the adult family home was well-maintained and provided a homelike environment for 1 of 1 resident. N424 DHS88.06(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 1 and Resident 2. - Resident 1's ISP was not updated to reflect a change in the level of supervision needed. - Resident 2's ISP was not updated to reflect elopement interventions. Resident 2 eloped from the facility 6 times.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 550 DHS 88.10(3)(b) Privacy

     Based on observation and interview, the provider did not ensure 2 of 2 residents had privacy in their own home.

     Statement of deficiencies (PDF)

   • Severity not stated

     N 582 DHS 88.10 (3)(q) Medications

     Based on record review, interview and observation, the provider did not ensure residents received medications as they were prescribed for Resident 1. - Resident 1 was protectively placed and had a corporate guardian. Resident 1 stayed overnight at a family member's house and the Licensee did not ensure Resident 1 had his/her medications. 0023 50.65(4m)(b) Caregiver Hiring and Contracting Process Based on record review and interview, the facility 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) Cross Reference Z0023 DHS 50.065(4m)(b) Caregiver Hiring and Contracting Process Cross Reference M0134 DHS 88.03(5)(e)(1) Significant Change To The Resident Cross Reference M0218 DHS 88.04(2)(b) Awake Staff for Continuous Care Cross Reference M0230 DHS 88.04(2)(f) Condition Which Represents Risk or Harm Cross Reference M0276 DHS 88.05(3)(a) Homelike Environment Cross Reference M0424 DHS 88.06(3)(f) Review of ISP Cross Reference M0582 88.10(3)(q) Medications

     Statement of deficiencies (PDF)

   • Severity not stated

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

     Based on record review and interview, the facility 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 8:15 AM, Surveyors requested a staff roster from Licensee A. Licensee A stated s/he had left all staff go and that s/he was the only one working. Surveyors asked Licensee A when Caregiver B had started employment and when s/he left and requested Caregiver B's record. Caregiver B's record identified the following: -Caregiver B had a hire date of 04/27/2026 -Caregiver B's Department of Justice, dated 04/27/2026, noted that Caregiver B 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 was currently working at the sister facility. 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/

     Statement of deficiencies (PDF)