Complete Care at Christian Home: Brain Injury Probe Failures - WI
The resident, identified in federal inspection records only as Resident 1, had been living at the facility on Fox Lake Road in Waupun with a cluster of conditions that made her particularly vulnerable: cognitive communication deficits, repeated falls, difficulty walking, and muscle wasting. A mental status exam completed five days before the brain bleed was discovered rated her as moderately cognitively impaired, meaning she could not reliably describe what had happened to her or when.
On October 1, 2025, the facility learned that Resident 1 had been found to have a subdural hematoma, a collection of blood that accumulates between the brain and the inner layer of the skull. The cause was unknown. The facility classified it as an injury of unknown origin and, according to its own policy, was obligated to investigate.
That investigation never happened. Not in any meaningful sense.
By the morning of October 14, when a federal surveyor sat down with Nursing Home Administrator A to ask about the case, the facility had been aware of the brain bleed for nearly two weeks. The administrator confirmed that the Director of Nursing, DON B, had started getting statements from staff. The surveyor asked to see them.
No statements were provided.
The surveyor asked whether staff statements were expected as part of the investigation. The administrator said yes, statements are part of a thorough investigation. The statements simply did not exist. DON B confirmed this directly when interviewed later the same day: staff had been talked to about the subdural hematoma, she said, but no written statements were obtained.
Talking to someone and documenting what they said are different things. In an abuse investigation, only one of them creates a record.
The facility's own policy, dated February 2025, spells out the obligation plainly. All unexplained injuries, including bruises, abrasions, and injuries of unknown source, will be investigated. The policy goes further: an injury of unknown source shall be investigated even if the resident is discharged from the facility as a result of the injury, or if the injury is identified after discharge. There is no carve-out for cases where the cause remains unclear. There is no provision that allows the investigation to consist of informal conversations that leave no trace.
A subdural hematoma in a nursing home resident with repeated falls and moderate cognitive impairment is not a routine paperwork problem. It is the kind of injury that requires an explanation, because the range of possible causes includes abuse. Federal rules require facilities to investigate potential abuse allegations thoroughly precisely because vulnerable residents often cannot speak for themselves, and because staff who harm residents rarely volunteer the information. Written statements, collected while memories are fresh, are among the most basic tools available.
Resident 1, with a mental status score indicating moderate cognitive impairment, was not in a position to provide that account herself.
The facility did produce some documentation of its response to the incident. The administrator showed the surveyor pre- and post-tests from falls prevention training given to 21 staff members, framed as part of a process improvement project launched after Resident 1's injury. The surveyor asked about the remaining 19 staff members who had worked at the facility during the same period. The administrator acknowledged that none of them had received the training yet, that additional training was planned, and that all staff should have it.
Falls prevention education is not an investigation. Training staff on how to prevent future falls does not establish what caused the brain bleed that already occurred, who was present, what staff observed, or whether anything that happened to Resident 1 before October 1 should have prompted an earlier report.
The inspection was a complaint survey, meaning someone contacted regulators about conditions at the facility before the October 14 visit. The inspection report does not identify the complainant or describe what prompted the complaint. It identifies only one resident reviewed for abuse out of three, and it is Resident 1's case alone that produced a cited deficiency.
Complete Care at Christian Home sits in Waupun, a city of roughly 11,000 people in Dodge County, about midway between Madison and Green Bay. The facility operates under a limited liability company structure.
What the inspection record leaves unresolved is the question the investigation itself was supposed to answer: how did Resident 1 develop a subdural hematoma? The injury is serious. Blood accumulating between the brain and skull creates pressure that can cause headaches, confusion, weakness, and, if left untreated, death. In an elderly person with cognitive deficits and a history of falls, a subdural hematoma can result from a fall the resident cannot remember or describe. It can also result from something else entirely.
The facility's failure to collect written statements means that whatever staff members observed in the days and hours before October 1 exists now only in their memories, unrecorded and unverified. If any of those staff members leave the facility, those accounts go with them. If a pattern existed, the paperwork that might have revealed it was never created.
The administrator, when asked by the surveyor, confirmed that the facility had treated this as an injury of unknown origin requiring investigation. The administrator confirmed that written statements are part of a thorough investigation. The administrator confirmed that falls prevention training had not yet reached all staff who needed it. Each of those admissions appeared in the surveyor's notes as evidence of the deficiency, not as a defense against it.
DON B's account added nothing to contradict the record. Staff were talked to. Nothing was written down.
Resident 1's current condition is not described in the inspection report. Whether she remained at the facility, was hospitalized, or was discharged is not stated. What caused the blood to collect between her brain and skull remains, as of the date of the inspection, officially unknown, and the investigation that might have narrowed the possibilities was never completed.
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 violations during a health inspection on October 14, 2025.
The facility classified it as an injury of unknown origin and, according to its own policy, was obligated to investigate.
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.