Christian Community Home: Pressure Injury Failures - WI
The admission came during a May 27 complaint inspection at the 65th Avenue facility. What inspectors found beneath it was a system, if it could be called that, in which nurses were not expected to look at residents' skin, nobody checked whether the weekly bath sheets were being completed, and the facility had no way to confirm that vulnerable residents were being turned and repositioned at all.
The physician assistant, identified in the inspection report as PA H, told the surveyor that the belief is all pressure injuries should be preventable. Asked whether any alternative interventions had been attempted for the resident, PA H said no. Asked whether the facility's outside wound resource had been contacted, PA H said no, that the wound nurse handles it.
The wound nurse, identified as Wound Nurse C, said the outside resource is a wound specialty provider that visits the facility monthly to review residents with pressure injuries and other skin issues. Asked whether that provider had been contacted about this resident, Wound Nurse C said no.
The resident, identified only as R1, had developed a new pressure injury. The inspection report does not describe its severity or location, but the citation carries a harm level of minimal harm or potential for actual harm.
What the inspection does describe, in detail, is how little oversight existed around the conditions that allow pressure injuries to develop.
Licensed Practical Nurse I told the surveyor that certified nursing assistants fill out a skin sheet on each resident once a week on bath day and report any concerns to the nurse. The surveyor asked whether nurses are expected to assess skin alongside the CNA on bath day. No, LPN I said, only the CNAs do it. Asked whether nurses complete their own weekly skin assessments, LPN I said no, not unless a CNA reports a concern. Asked whether nurses review the completed bath sheets, LPN I said no, not unless a CNA flags something.
So the entire early-warning system for skin breakdown rested on a CNA mentioning it.
The Clinical Nurse Manager, identified as CNM J, described a different expectation: nurses should document at least weekly on skin condition after the bath sheet is completed. But when the surveyor asked whether anyone was reviewing or monitoring whether those weekly skin checks were actually being documented, CNM J said no. When asked whether anyone was tracking if the bath sheets themselves were being completed, CNM J said no.
The surveyor then asked how staff document when residents are repositioned or when incontinence briefs are checked and changed. CNM J said there is no current practice in place for staff to document this. Staff are expected to turn and reposition residents frequently, CNM J said, but asked how the facility monitors whether that is actually happening for residents at risk, CNM J said no process is currently in place.
No documentation of repositioning. No review of skin assessments. No monitoring of whether the assessments happen at all. A wound specialist coming through the building every month who was never called about a resident developing a new wound.
The facility's own clinical nurse manager, when asked directly, could not point to a single mechanism that would tell anyone whether a resident at risk for pressure injuries was being turned.
Pressure injuries, commonly called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue, most often in residents who cannot reposition themselves. They are closely associated with how consistently staff move immobile residents and how quickly early skin changes are caught and acted on. A resident who goes unturned, or whose early skin changes go unnoticed because no nurse looks and no record is kept, is a resident whose injury can deepen from a surface redness into an open wound before anyone with authority to intervene knows it exists.
The inspection report does not say how long R1's pressure injury had been developing before it was identified, or what stage it reached.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Christian Community Home of Osceola, Inc from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
CHRISTIAN COMMUNITY HOME OF OSCEOLA, INC in OSCEOLA, WI was cited for violations during a health inspection on May 27, 2026.
The admission came during a May 27 complaint inspection at the 65th Avenue facility.
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.