Complete Care at Christian Home LLC learned on October 1st that a resident had sustained a subdural hematoma — a collection of blood that accumulates between the brain and the inner layer of the skull — but administrators never collected written statements from staff members who cared for the patient.
The resident, identified in inspection records as R1, had been admitted with multiple diagnoses including cognitive communication deficit, repeated falls, difficulty walking, and muscle wasting. A mental status assessment on September 26th scored the resident at 9 points, indicating moderate cognitive impairment.
When federal inspectors arrived two weeks later, they found a facility that had classified the brain injury as requiring investigation but had abandoned the process midway through.
Nursing Home Administrator A told inspectors the facility "looked at the situation as an injury of unknown origin as they did not know how the subdural hematoma occurred." The administrator said Director of Nursing B had "started getting statements from staff."
But no staff statements were provided when inspectors requested them.
The administrator acknowledged that staff statements "are a part of a thorough investigation" and are expected in such cases. The facility's own policy, dated February 2025, requires investigation of all unexplained injuries, including those discovered after a resident's discharge.
Instead of collecting statements, the facility launched staff education on falls prevention as part of what administrators called a "process improvement project." Pre and post-test results were provided for 21 staff members.
When inspectors asked about training for the remaining 19 staff members who had worked since the education began, Administrator A said no additional documentation existed. The facility was "planning for additional training as they worked through their PIP, but it had not yet occurred."
The administrator agreed that all staff should receive the training.
Director of Nursing B confirmed the incomplete investigation during a separate interview. The nursing director stated that "staff were talked to about the subdural hematoma, but no written statements were obtained."
The facility's policy explicitly requires investigation even when a resident is discharged following an injury or when an injury is identified after discharge. The policy states that "all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated."
Federal regulations require nursing homes to respond appropriately to all alleged violations and conduct thorough investigations when injuries of unknown origin occur. The failure to collect staff statements represents a fundamental breakdown in the investigation process designed to protect vulnerable residents.
R1's medical history made the resident particularly susceptible to injury. The combination of cognitive impairment, repeated falls, walking difficulties, and muscle wasting created multiple risk factors that required careful monitoring and documentation when injuries occurred.
Subdural hematomas can result from various causes, including falls, medication effects, or other trauma. In elderly residents with cognitive impairment and a history of falls, determining the cause becomes crucial for preventing future incidents and ensuring appropriate care.
The facility's response focused on education rather than investigation. While falls prevention training addresses systemic issues, it doesn't fulfill the regulatory requirement to thoroughly investigate how a specific resident sustained a serious brain injury.
The incomplete investigation means the facility may never determine what caused R1's subdural hematoma. Without staff statements detailing their observations and interactions with the resident, administrators lack critical information about the circumstances surrounding the injury.
This information gap extends beyond R1's case. Other residents with similar risk factors — cognitive impairment, fall history, mobility issues — remain potentially vulnerable to the same unknown circumstances that led to R1's brain injury.
The facility's process improvement project, while addressing general falls prevention, cannot substitute for the forensic investigation required when serious injuries occur. Staff statements provide specific details about a resident's condition, behavior, and care in the hours or days preceding an injury discovery.
Federal inspectors found that the facility "failed to complete a thorough investigation for an injury of unknown origin." The violation received a minimal harm designation, indicating the deficiency created potential for actual harm rather than immediate jeopardy to residents.
Complete Care at Christian Home operates at 452 Fox Lake Road in Waupun, serving residents with complex medical and cognitive needs. The facility's investigation policies recognize the importance of determining injury causes, but implementation fell short when a resident sustained serious brain trauma.
The case highlights the challenge nursing homes face in balancing immediate response with thorough investigation. While the facility moved quickly to implement falls prevention education, the fundamental question of how R1 sustained a subdural hematoma remains unanswered.
Without staff statements, the facility cannot identify whether the injury resulted from an unwitnessed fall, medication interaction, underlying medical condition, or other factors. This knowledge gap compromises the facility's ability to protect R1 and other vulnerable residents from similar injuries.
The investigation failure occurred despite clear policy requirements and the administrator's acknowledgment that staff statements are essential components of thorough investigations. The gap between policy and practice left a cognitively impaired resident's serious brain injury unexplained and potentially preventable future incidents unaddressed.
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.
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