Complete Care at Christian Home: Fall Safety Failures - WI
Not once. Not after the second fall, or the fifth, or the seventh.
State and federal inspectors who visited the facility on October 14, 2025 rated what they found as causing actual harm. The deficiency, documented under F0689, centers on a man identified in inspection records only as R1. His care plan, which is supposed to guide how staff protect him and respond to his specific risks, contained no fall interventions of any kind despite a documented history that stretched across seven separate incidents.
The registered nurse on staff, identified as RN I, told inspectors exactly what should have happened each time R1 went down. An incident report needs to be completed. Assessments get triggered automatically when that report is filed, including a Post Fall Assessment. The point of all of it, RN I explained, is to figure out why the fall happened and put something in place to stop the next one. Staff are then supposed to check on the resident and document those checks every shift for 72 hours.
Whether any of that happened for R1 after any of his seven falls, the inspection record does not say. What it does say is that his care plan showed none of it.
The licensed practical nurse responsible for maintaining care plans, identified as LPN J, sat down with the surveyor and reviewed R1's file together. LPN J confirmed what the surveyor had already found: nothing in R1's care plan reflected any of his falls. No updated interventions. No documented changes in approach. Seven falls, and the care plan looked as though none of them had occurred.
LPN J explained how the system is supposed to work. She updates care plans after completing MDS assessments and after the morning interdisciplinary team meetings, where staff discuss residents and adjust approaches. Fall interventions decided in those morning meetings, she said, should make it into the care plan. She added that care plans should be updated as soon as possible when new information comes in.
Then she identified the gap. If she doesn't attend the morning IDT meeting, or if no one tells her that new interventions were discussed, she wouldn't know the care plan needed changing. The inspection record cuts off before capturing her full answer about what the process is supposed to be when she isn't in the room.
That gap, whatever its cause, left R1 without a care plan that reflected his actual situation. Seven falls is not a minor oversight in documentation. A care plan exists precisely so that every nurse and aide who walks into a resident's room knows what that person's risks are and what the team has decided to do about them. Without that updated record, the next staff member coming on shift has no way of knowing that this particular resident has fallen seven times, or what, if anything, has been tried to keep him safe.
The facility is located at 452 Fox Lake Road in Waupun, a small city in Fond du Lac County. The inspection was conducted as a complaint survey, meaning someone, whether a resident, family member, or staff, had already raised concerns before inspectors arrived.
The violation was tagged at a level of harm described as actual harm, affecting few residents. The language matters. Actual harm is a specific regulatory determination, one step below immediate jeopardy, meaning inspectors concluded that what happened to R1 was not a near-miss or a paperwork problem. Something real went wrong for him.
What that harm looked like for R1, whether another fall, an injury, a worsening condition that better monitoring might have caught, is not described in the portion of the inspection record available. His name is not given. His age, his diagnosis, the nature of his falls, what he experienced across those seven incidents, none of that appears in the record.
What the record shows is a man who fell, and fell again, and kept falling, while the document meant to protect him stayed unchanged.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Christian Home LLC from 2025-10-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
Complete Care at Christian Home LLC in Waupun, WI was cited for violations during a health inspection on October 14, 2025.
Not after the second fall, or the fifth, or the seventh.
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.