Complete Care at Christian Home: Abuse Probe Failures - WI
Not incomplete. Not partial. None.
The facility, at 452 Fox Lake Road in Waupun, became aware on October 1, 2025, that a resident identified in inspection records only as Resident 1 had been found to have a subdural hematoma. A subdural hematoma is a collection of blood that accumulates between the brain and the inner layer of the skull, often caused by a head injury. Nobody at the facility could say how this one happened.
Resident 1 had been admitted with a list of conditions that made her both vulnerable and difficult to assess: cognitive communication deficit, a history of repeated falls, difficulty walking, and muscle wasting and atrophy. A mental status evaluation conducted just five days before the facility learned of the brain bleed, on September 26, gave her a score of 9, placing her in the moderately cognitively impaired range. She could not reliably explain what had happened to her. That made the staff investigation more important, not less.
The facility's own policy, updated as recently as February 2025, was explicit on this point. All unexplained injuries would be investigated. That obligation did not expire if the resident left the building. The policy stated that an injury of unknown source would be investigated even after discharge.
When the inspector sat down with Nursing Home Administrator A on the morning of October 14, the administrator described what the facility had done. The Director of Nursing, identified in records as DON B, had started getting statements from staff. The administrator used the past tense. The inspector asked to see them.
No statements were provided.
The inspector asked whether staff statements were expected as part of a thorough investigation. The administrator said yes, statements are part of a thorough investigation. The inspector was talking to the person responsible for the building's operations, who had just confirmed that the investigation was incomplete by the facility's own standard, and who had no statements to hand over.
What the facility did have were pre- and post-tests from a falls prevention education program, completed by 21 staff members. The administrator presented these as evidence of a response, a process improvement project launched in the wake of the incident. The inspector looked at the number and asked about the other 19 staff members who had worked at the facility during the same period. The administrator said no, there was no documentation of training for them yet. The facility was planning additional sessions, but they hadn't happened.
The inspector asked whether all staff should have received the training. The administrator said yes.
So: no written statements. Training completed for roughly half the relevant staff. A brain bleed with no known cause, in a resident who could not speak for herself.
That afternoon, the inspector spoke with DON B directly. The director confirmed what the administrator had already acknowledged. Staff were talked to about the subdural hematoma. But no written statements were obtained.
Talked to, but not documented. Conversations that leave no record, that cannot be reviewed, that cannot be compared against other accounts, that cannot be used to determine whether anyone knew something about how a woman ended up with blood pooling inside her skull.
The inspection report, completed October 14, 2025, cited the facility for failing to complete a thorough investigation in response to a potential allegation of abuse. The deficiency covered one of three residents reviewed for abuse during the complaint inspection.
The word "abuse" carries weight in this context. A subdural hematoma of unknown origin in a cognitively impaired resident who cannot explain her own injuries is, under federal inspection standards, a potential abuse allegation until an investigation rules otherwise. That is not a bureaucratic formality. It is the framework that exists precisely because residents like this one cannot protect themselves or tell anyone what happened.
The investigation that might have answered the question, or at least narrowed the possibilities, was never finished. Fourteen days passed between October 1, when the facility learned of the hematoma, and October 14, when the inspector arrived. Fourteen days during which DON B talked to staff without writing anything down, during which the administrator believed an investigation was underway, during which falls prevention training was organized and delivered to 21 of the 40 staff members who needed it.
Fourteen days, and no written record of what any staff member said about how this happened.
The facility's February 2025 policy did not require a thorough investigation because thorough investigations are a bureaucratic preference. It required one because the alternative, in a locked building full of people who cannot always speak for themselves, is that harm goes unrecorded and unaddressed, and the people responsible for it continue working.
Complete Care at Christian Home is a nursing facility operating under the umbrella of the Complete Care management network. The Waupun location sits on Fox Lake Road on the edge of a small city in Dodge County. The residents it serves are, by the nature of the population, people who depend entirely on the staff around them, on the administrators who set policy, on the directors of nursing who conduct investigations, to notice when something is wrong and pursue it until there is an answer.
Resident 1 had a brain bleed. The facility does not know why. The people who might know were spoken to informally and then, apparently, the conversation ended.
The inspector's report notes the harm level as minimal or potential for actual harm. That designation reflects the regulatory classification of the deficiency, not a conclusion about what happened to Resident 1. What happened to Resident 1 remains, as of the date of inspection, unknown, because the investigation that might have found out was never completed.
She had repeated falls in her history. She had muscle weakness. She had cognitive deficits that made communication difficult. Any of those facts could be part of an innocent explanation. They could also be the context in which something else happened, something that a written statement from a staff member, taken in the first days after October 1, might have clarified.
Nobody wrote those statements down. Fourteen days later, an inspector came and asked for them, and the administrator confirmed they didn't exist, and confirmed they should have.
Resident 1's name is not in the inspection report. Her age is not there, nor the date she was admitted, nor what became of her after the hematoma was discovered, whether she recovered or declined, whether she is still at the facility or was discharged, whether she is alive. The report does not say. The investigation that might have produced answers about what happened to her was never finished.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 20, 2026 · Our methodology
Complete Care at Christian Home LLC in Waupun, WI was cited for abuse-related violations during a health inspection on October 14, 2025.
A subdural hematoma is a collection of blood that accumulates between the brain and the inner layer of the skull, often caused by a head injury.
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.