Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Christian Home Llc during CMS and state inspections, most recent first.
Failure to Assess Wounds and Change in Condition: A resident with diabetes developed a heel blister without documented daily foot checks, a complete wound assessment, or timely MD notification, and the wound later worsened. Another resident’s toe wound was not assessed or measured on admission despite being listed in hospital paperwork. A third resident had repeated gagging and emesis with no documented assessment or provider update before hospitalization for a UTI.
A resident admitted with a cervical collar and no initial pressure injury developed an unstageable pressure injury on the back of the head from the collar. The care plan called for weekly skin checks and routine skin observation, but the record lacked documentation of skin checks under the device. Survey findings showed the wound was identified as a pressure wound from the rigid cervical collar, and RN H did not follow the wound treatment order during care, including omitting peri-wound skin prep and applying an ABD pad without an order.
The facility failed to maintain an effective infection prevention and control program after Legionella-positive water tests were found in multiple locations. Staff reported water heater temperatures were kept at 111-116°F for scalding purposes, below the level they believed was needed to kill Legionella, and acknowledged the facility lacked anti-scald protection. Despite repeat positive results, the facility did not implement the water management plan’s listed interventions for the affected resident room, and no additional testing was done to confirm the control measures were effective.
Failure to provide requested shaving assistance: A resident with Parkinson's disease, weakness, lack of coordination, and mild cognitive impairment stated a preference to be clean shaven but was observed with facial hair for three consecutive days. Care plan and task charting showed varying levels of ADL assistance, with no refusal documented. A CNA said shaving could be done daily and an LPN confirmed the resident had not been shaved, while the DON stated shaving should be offered daily.
Medication administration errors exceeded the allowed rate, with 2 errors out of 25 opportunities. An RN prepared to crush a resident’s pantoprazole DR tablet even though the medication card stated not to crush it, and another RN administered insulin lispro without priming the pen and without holding the needle in place after the injection. The facility policy and insulin pen instructions required correct administration methods, including no crushing of delayed-release medication and priming plus a post-injection hold time for insulin pens.
A resident with multiple chronic conditions experienced a significant change in condition, including increased unresponsiveness and difficulty swallowing. The assigned RN did not perform a comprehensive assessment, failed to obtain vital signs, and did not communicate detailed findings to the physician. The resident's condition worsened throughout the day, leading to hospital transfer for hypothermia and dehydration, where aggressive interventions were required.
Two residents with a history of falls did not receive adequate supervision or timely interventions to prevent further accidents, resulting in multiple unwitnessed falls and injury, including a subdural hematoma. The facility failed to complete thorough post-fall assessments, root cause analyses, and care plan updates as required by policy, with documentation and communication lapses among staff contributing to the deficiency.
A resident with cognitive impairment and a history of falls was found to have a subdural hematoma, but the facility did not complete a thorough investigation as required by policy. Staff were verbally questioned, but no written statements were obtained, and not all staff received documented training on falls prevention during the relevant period.
A resident with multiple chronic conditions did not receive adequate monitoring of fluid intake, despite being at risk for dehydration and having a documented daily fluid requirement. Staff failed to consistently track or respond to insufficient fluid intake, and the care plan did not address dehydration risk. The resident developed severe dehydration, resulting in hospitalization and subsequent decline.
A resident with multiple diagnoses experienced significant weight loss and a bleeding episode, but the facility did not promptly notify the physician as required by policy. Both nursing staff and the nurse practitioner confirmed that immediate notification was expected for these changes, but no documentation of timely notification was found.
A resident was prescribed Trazodone for sleep without a proper diagnosis of insomnia or a comprehensive sleep assessment, contrary to facility policy. Documentation of sleep issues was minimal, and there was no evidence of non-pharmacological interventions being attempted before starting the medication. The DON confirmed the lack of a structured process for sleep assessment and monitoring.
Failure to Assess Wounds and Change in Condition
Penalty
Summary
The facility did not ensure that treatment and care were provided in accordance with professional standards for residents with wounds and a change in condition. One resident with diabetes and peripheral vascular disease developed a blister on the right heel, but the record did not show daily diabetic foot checks from admission through discovery of the wound. When the heel wound was first noted, the nurse documented a blister that had peeled back and applied a dressing, but there was no complete wound assessment documented at discovery and the physician was not updated timely. The wound later required outside wound care, and the documentation showed the heel wound had enlarged and developed necrotic tissue over time. A second resident was admitted with multiple diagnoses including diabetes, acute kidney failure, heart failure, cellulitis, and atrial fibrillation. The admission skin assessment documented blisters on the right lower extremity related to cellulitis and treatment already in place, but the resident’s right big toe wound was not assessed, measured, or documented on admission. Hospital discharge paperwork showed a wound at the base of the right big toe, and the first nursing progress note mentioning the toe wound did not appear until several days later. Facility leadership stated that all wounds should be included in the initial skin assessment with measurements and treatments. A third resident had a change in condition with repeated complaints of not feeling well, gagging, and emesis. Progress notes documented the resident appearing different, tearful, spitting into a basin, and having medium emesis on more than one occasion. The record did not show vital signs for those days, and there was no documented assessment or provider update related to the episodes. The resident was hospitalized the following day after a noted change in condition and was admitted with a urinary tract infection.
Failure to Monitor Skin Under Cervical Collar Led to Unstageable Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident admitted without a pressure injury did not develop a pressure injury and failed to provide care and services consistent with professional standards to prevent the development or worsening of pressure injuries. R5 was admitted with a cervical collar and diagnoses including a displaced type 2 dens fracture, diabetes mellitus, and peripheral vascular disease. The resident was admitted without a pressure injury to the neck or back of the head, and the record showed no physician order directing staff to check the skin under or around the cervical collar. R5’s care plan identified skin integrity risks and included weekly skin checks and observation of the skin during morning and evening cares, but survey review found no documentation of skin checks under the cervical collar. On 4/8/26, the wound doctor documented an unstageable pressure injury on the head, described as a pressure wound from a rigid cervical collar at the left/middle occipital area, with thick adherent necrotic tissue and moderate sero-sanguinous drainage. The wound treatment plan ordered calcium alginate, a foam silicone border dressing, and skin prep to the peri-wound area. During observation of wound care on 4/14/26, RN H cleansed the wound, applied mepilex, and placed an ABD pad for comfort, but did not apply skin prep to the peri-wound and there was no order for the ABD pad. RN H stated staff were checking under the collar daily but were not documenting those checks and were not completing the weekly assessments. DON B stated staff should check under a device at least every shift and expected the skin under the cervical collar to be checked, while MD J stated staff should be checking the skin under the collar. The surveyor concluded that R5 developed a medical device-related pressure injury because nursing staff were not checking the skin under the cervical collar daily.
Failure to Maintain Effective Legionella Water Management Program
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The deficiency involved the facility’s water management program after Legionella-positive test results were identified in multiple locations, including a break room sink, a shower, R22’s room sink, and other shower areas. The facility’s policy stated that a water management program was part of the infection prevention and control program, with the Maintenance Director serving as the leader, and the water management plan required validation testing and response to any Legionella-positive sample. Surveyor interview and record review showed that the facility’s water heater temperatures were maintained below the level the facility acknowledged was needed to kill Legionella. MT C stated the water heater was at 111 degrees Fahrenheit for scalding purposes and later set at 116 degrees Fahrenheit, with resident rooms ranging from 111 to 114 degrees Fahrenheit. MT C also stated the facility could not keep the water heater temperature high enough because it did not have anti-scald protection. The facility had positive Legionella results on the initial sampling and on repeat sampling, but staff stated they believed the numbers were low and did not implement the interventions listed in the water management plan’s response guidance. The surveyor also reviewed R22’s room, where the resident stated he or she washed up at the bathroom sink and used the sink for face washing and brushing teeth. DON/IP B acknowledged that water used for brushing teeth could be consumed and that there was a potential for aspiration during brushing. Despite this, the facility did not provide additional interventions for R22’s room to reduce exposure, and staff stated there was no further action beyond additional flushing. The facility also did not do additional testing to determine whether the control measures were effective after the positive Legionella findings.
Failure to Provide Requested Shaving Assistance
Penalty
Summary
The facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one resident reviewed for grooming. The resident stated a preference to be clean shaven, but was observed with facial hair over the cheeks, chin, and neck for three consecutive days. The resident had diagnoses including Parkinson's disease, weakness, lack of coordination, and mild cognitive impairment, and the MDS indicated a BIMS score of 13, showing the resident was cognitively intact. The resident's care plan identified deficits with ADLs and included hygiene assistance, and the task charting for personal hygiene showed a mix of dependent, partial/moderate assist, and substantial/maximal assist, with no documentation of refusal. During interviews, a CNA stated residents are shaved on bath days and if they request it on other days, and that the resident could be shaved daily, but was not sure it had been offered that day. An LPN stated residents are usually shaved on bath day, confirmed the resident's bath was on 4/13/26, and stated the resident had not been shaved. The DON stated shaving should be offered daily.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure that medication error rates remained below 5 percent. Surveyors identified 2 medication errors out of 25 opportunities, affecting 2 of 8 residents observed during the medication administration task, for an error rate of 8%. The facility policy stated that medications must be administered safely and in accordance with the order, including the right resident, medication, dosage, time, and method of administration. For one resident with diagnoses including GERD and a history of peptic ulcer disease, the physician ordered pantoprazole sodium oral tablet delayed release 20 mg once daily. During observation, an RN placed seven tablets into a plastic bag to crush for administration, and one of the tablets was the resident’s pantoprazole DR. The surveyor stopped the nurse before the medication was crushed. The nurse then reviewed the medication card, saw that the pantoprazole was delayed release, and removed it from the bag after recognizing it should not be crushed. For another resident receiving insulin lispro (Humalog), the surveyor observed an RN apply a needle to the insulin pen and dial the dose to 14 units, but the nurse did not prime the pen before administration and did not keep the needle in the skin after the dose was given. The facility’s insulin pen policy required priming before each use and keeping the needle in the skin for 6 to 10 seconds after injection. The surveyor reviewed the manufacturer’s instructions with the nurse, and the DON stated that insulin pens need to be primed prior to setting the dose and the needle must remain in place for at least 10 seconds after administration.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide appropriate assessment and care for a resident who exhibited a significant change in condition. The resident, who had a history of Parkinson's disease, anemia, hyponatremia, chronic kidney disease, congestive heart failure, and hypertension, was noted by staff and family to be less responsive, exhibiting increased shaking, drooling, and difficulty swallowing. Despite these changes, the RN did not perform a comprehensive assessment, did not obtain vital signs, and did not provide a detailed report to the physician. The only action taken was to verbally notify the Director of Nursing (DON) and request that the physician look at the resident, which resulted in lab work being ordered for the following day. There was no documentation of a thorough assessment or timely communication of the resident's deteriorating condition to the physician. Throughout the day, the resident's condition continued to decline. Certified Nursing Assistants (CNAs) and other nursing staff observed that the resident was unable to eat or swallow, was minimally responsive, and required more assistance with transfers than usual. The second shift nurse, upon being informed of the resident's status, performed an assessment, obtained vital signs, and found the resident to have a low oxygen saturation. The resident was subsequently placed on supplemental oxygen and transferred to the emergency department, where he was found to be unresponsive, hypothermic, dehydrated, and suffering from multiple abnormal lab values. The emergency department initiated aggressive warming and hydration measures, and the resident was admitted for comfort care. Interviews with facility staff confirmed that the RN on the day shift did not follow professional standards of practice as outlined in the Wisconsin Nurse Practice Act and facility expectations. The DON and physician both stated that the expectation was for the nurse to assess the resident, obtain vital signs, and communicate findings to the physician. The RN admitted to not completing an assessment or obtaining vital signs, and documentation was not completed in a timely manner. The facility was unable to provide a change in condition policy when requested by the surveyor.
Failure to Provide Adequate Supervision and Fall Prevention for Residents at Risk
Penalty
Summary
The facility failed to ensure that residents at risk for falls received adequate supervision and timely, appropriate interventions to prevent accidents. Two residents with a history of falls experienced multiple unwitnessed falls, with one resident suffering a subdural hematoma. Despite repeated incidents, the facility did not complete thorough post-fall assessments, root cause analyses, or timely updates to care plans. Documentation was often incomplete, with missing or partially filled vital signs and neurological check sheets, and post-fall assessments were sometimes delayed by weeks. For one resident with cognitive impairment, lymphedema, atrial fibrillation, and a history of repeated falls, there were seven unwitnessed falls while self-transferring. The facility did not conduct immediate or comprehensive assessments after these falls, nor did it update the resident's care plan with new interventions. The interdisciplinary team (IDT) reviews and root cause analyses were either not completed or significantly delayed, and care plan updates were not made to reflect new risks or interventions. Staff interviews confirmed that care plans were not consistently updated after falls, and that communication lapses contributed to the lack of timely intervention. Another resident, identified as at risk for falls upon admission, experienced eight falls without the facility identifying root causes, trends, or updating the care plan accordingly. Facility policies required comprehensive post-fall assessments, care plan reviews, and implementation of individualized interventions, but these were not followed. Staff interviews revealed inconsistent understanding and execution of fall prevention protocols, and documentation did not reflect the required monitoring or follow-up after falls.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for one resident who was found to have a subdural hematoma. According to the facility's policy, all unexplained injuries, including those of unknown source, must be investigated, even if the resident is discharged or the injury is discovered after discharge. The resident in question had a history of cognitive impairment, repeated falls, difficulty walking, and muscle wasting. The facility became aware of the subdural hematoma but did not obtain written statements from staff as part of the investigation, despite this being an expected component of a thorough inquiry. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that while staff were verbally questioned about the incident, no written documentation of their statements was collected. The NHA acknowledged that staff statements are a required part of the investigation process. Additionally, although some staff received education on falls prevention as part of a process improvement project, not all staff who worked during the relevant period had completed the training, and there was no documentation for the remaining staff. This incomplete investigation did not meet the facility's own policy requirements for responding to injuries of unknown origin.
Failure to Monitor and Maintain Adequate Hydration Leading to Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding hydration. The resident, who had multiple diagnoses including Parkinson's disease, anemia, hypo-osmolality, hyponatremia, chronic kidney disease, congestive heart failure, and hypertension, was assessed to require 2,350 cc of fluids per day. Despite this, fluid intake records showed that the resident consistently received less than the estimated daily fluid needs on nearly all documented days, with only one day meeting the requirement. The care plan did not address the resident's risk for dehydration, and there was no evidence of a dehydration assessment, comprehensive RN assessment, or provider notification when fluid goals were not met. Staff interviews revealed a lack of clarity and responsibility regarding monitoring fluid intake for residents not on fluid restrictions. The RN stated that fluid intake was only monitored for residents on fluid restrictions, and was unaware of how to identify residents at risk for dehydration through care plans or Kardex. The DON indicated that all residents are at risk for dehydration but was unsure who was responsible for ensuring fluid goals were met, suggesting the dietician was responsible but also expressing uncertainty about the process. There was no documentation that the dietary manager or registered dietitian was notified when the resident failed to meet fluid needs over multiple days. The resident experienced a significant change in condition, including altered mental status, lethargy, increased confusion, increased shaking, and weakness, leading to hospitalization. Emergency department records documented the resident as unresponsive, hypothermic, and dehydrated, with abnormal laboratory values indicating dehydration and renal impairment. The resident was treated with IV fluids and admitted to the hospital, later returning to the facility on hospice care and subsequently passing away. The failure to monitor and address the resident's hydration status directly resulted in hospitalization for dehydration.
Failure to Timely Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify and consult with a resident's physician when there was a significant change in condition for one resident. Specifically, the facility did not report a significant weight loss in a timely manner to the resident's provider. The resident, who had diagnoses including vascular dementia, depression, and dysphagia, experienced a weight drop from 222.4 pounds to 196.8 pounds over a period of approximately three weeks. Both the RN and DON confirmed that such a weight loss was significant and required physician notification, but no documentation of such notification was provided. The nurse practitioner also confirmed that notification was expected and had not occurred. Additionally, the facility did not notify the physician immediately when the same resident experienced a large incontinent bowel movement with moderate to large amounts of blood. The incident was documented in the progress notes, and the resident was later sent to the hospital for evaluation. However, both the RN and DON acknowledged that the physician should have been notified at the time the bleeding was first observed in the morning, but this did not occur. The nurse practitioner confirmed that immediate notification was expected in such cases. The facility's own policies require prompt notification of the physician and resident representative in the event of acute illness or significant changes in the resident's condition, including weight changes and bleeding episodes. Despite these policies, the required notifications were not made or documented for the resident's significant weight loss and bleeding event.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs Due to Inadequate Sleep Assessment
Penalty
Summary
The facility failed to ensure that a resident’s medication regimen was free from unnecessary drugs, specifically by administering an antidepressant, Trazodone, for sleep without an appropriate diagnosis or adequate assessment. The resident, who had multiple diagnoses including dementia, Wernicke's encephalopathy, and alcohol dependence, was prescribed Trazodone for sleep despite lacking a documented diagnosis of insomnia. The only sleep assessment available was part of an admission tool, which noted some sleep difficulties but did not constitute a comprehensive evaluation or establish a clinical indication for the medication. There was no evidence of a formal sleep assessment or documentation of non-pharmacological interventions prior to starting the medication, as required by facility policy. Further review of the resident’s records showed minimal documentation of sleep issues, with insomnia only marked once in the behavior monitoring report. Progress notes and physician notifications referenced sleep difficulties and restlessness, but there was no consistent or detailed tracking of sleep patterns or hours. The DON acknowledged the absence of a structured process for sleep assessment and monitoring, and confirmed that sleep diaries were not used. The facility’s approach did not align with its own policy, which requires thorough documentation of indications for psychotropic medications and the use of non-pharmacological interventions before initiating such drugs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waupun
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Manor | 13 mi | ★★★★★ | 9 | 0 |
| Beaver Dam Health Care Center | 13.1 mi | ★★★★★ | 23 | 2 |
| Markesan Resident Home | 13.2 mi | ★★★★★ | 4 | 0 |
| Avina Of Mayville | 13.8 mi | ★★★★★ | 12 | 0 |
| Randolph Health Services | 14.1 mi | ★★★★★ | 11 | 0 |
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