Christian Community Home Of Osceola, Inc
CHRISTIAN COMMUNITY HOME OF OSCEOLA, INC in OSCEOLA, WI — inspection on May 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Survey Agency or local law enforcement within 24 hours after being made aware of the allegation for
email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. DON B did not submit a Misconduct Incident Report to the State Survey Agency after being made aware of concern.This is evidenced by:On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B (Director of Nursing) regarding concerns of neglect. CNA D stated upon starting her PM shift, CNA D entered R1's room and found R1's incontinent brief to be overly saturated with urine and R1's legs and chest were wet with urine. CNA D stated she checked the CNA report sheet, and no one had documented changing R1's incontinent briefs since 8:15 AM.
Surveyor asked CNA D if the DON had followed up with her after sending the email. CNA D stated no.
Surveyor asked CNA D if a copy of the email could be accessed. CNA D forwarded the email to Surveyor.On 05/26/26 at 8:58 AM, CNA D forwarded the email that was sent to DON B to Surveyor.
Surveyor noted the original email was time and date stamped as 05/10/26 at 10:56 PM.
The email stated: .[R1] was completely soaked in urine that seeped through the pad.soaker completely wet.and went down [R1's] leg.
While completing cares, [CNA K] entered room, and [CNA D] asked [CNA K] the last time [R1] was changed. [CNA K] stated having no time.[CNA D] stated this was unacceptable and felt this was neglect.Surveyor reviewed the facility's complaint/grievance log and noted no reported allegations of neglect.On 05/26/26 at 3:23 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding incident reporting.
Surveyor asked NHA A if any allegations of neglect had been reported in the last 3 months. NHA A stated no.On 05/26/26 at 5:02 PM, Surveyor interviewed DON B regarding allegations of neglect.
Surveyor asked DON B if any allegations of neglect had been reported in the last 3 months.
DON B stated no.
Surveyor clarified with DON B no allegations of neglect or concerns with quality of care from staff had been reported in person, email, or other written communication. DON B stated being positive no concerns like that had been brought to her attention. On 05/27/26 at 7:30 AM, Surveyor interviewed NHA A and DON B. DON B stated after our initial conversation, DON B reviewed emails and found the email from CNA D on 05/10/26.
Surveyor asked DON B why this allegation of neglect was not reported. DON B stated CNA D frequently makes unvalidated complaints about co-workers, is not credible, and did not see the word ?neglect' when initially reviewing the email. NHA A stated in retrospect, regardless of who made the allegation, this should have been reported to the State Agency within 24 hours.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
525706 05/27/2026
Christian Community Home of Osceola, Inc 2650 65th Ave Osceola, WI 54020
aware of a concern of neglect for 1 of 1 resident (R1) reviewed.On 05/10/26 at 10:56 PM, Director of
regarding R1.
The facility did not immediately begin a thorough investigation of reported neglect, collect information that corroborates or disproves the incident, and document the findings.This is evidenced by: On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B regarding concerns of neglect. CNA D stated upon starting her PM shift, CNA D entered R1's room and found R1's incontinent brief to be overly saturated with urine and R1's legs and chest were wet with urine. CNA D stated she checked the CNA report sheet, and no one had documented changing R1's incontinent briefs since 8:15 AM.
Surveyor asked CNA D if the DON had followed up with her after sending the email. CNA D stated no.
Surveyor asked CNA D if a copy of the email could be accessed. CNA D forwarded the email to Surveyor. On 05/26/26 at 8:58 AM, CNA D forwarded the email was sent to DON B (Director of Nursing) to Surveyor.
Surveyor noted the original email was time and date stamped as 05/10/26 at 10:56 PM.
The email stated: .[R1] was completely soaked in urine that seeped through the pad.soaker completely wet.and went down [R1's] leg.
While completing cares, [CNA K] entered room, and [CNA D] asked [CNA K] the last time [R1] was changed. [CNA K] stated having no time. [CNA D] stated this was unacceptable and felt this was neglect. R1 was admitted to the facility on [DATE]. R1's care plan, dated 05/05/25, states: Vulnerabilities: Potential for abuse/neglect from self or others. No goals or interventions documented.
No additional care plan interventions were implemented after allegation of neglect was reported on 05/10/26.
Surveyor reviewed R1's progress notes: Surveyor reviewed R1's medical record and noted no behavior monitoring implemented after allegation of neglect was reported on 05/10/26. No documentation of allegation of neglect was documented. No documentation notifying R1's Power of Attorney of neglect allegation was noted.
Surveyor reviewed the facility's complaint/grievance log and noted no reported allegations of neglect. On 05/27/26 at 7:30 AM, Surveyor interviewed DON B regarding investigation of reported allegation of neglect with R1. DON B stated receiving the email from CNA D on 05/10/26 but did not see the wording alleging neglect. DON B stated she attempted on 5 different occasions to interview CNA D and CNA K but they did not show up for the interviews.
Surveyor asked DON B if any documentation for an investigation being completed. DON B stated only having what she had documented on her computer. DON B stated as of 05/27/26, no interviews had been completed with R1, CNA D, CNA K or any other staff or residents regarding the allegation of neglect.
525706 05/27/2026
Christian Community Home of Osceola, Inc 2650 65th Ave Osceola, WI 54020
time.
Surveyor asked PA H if R1's new PI was preventable. PA H stated PA H's belief is all PIs should
additional interventions.
Surveyor asked PA H if this resource was used regarding R1. PA H stated no
(LPN) I regarding skin assessments. LPN I stated CNAs fill out a skin sheet on each resident once a week on bath day and report any concerns to the nurse.
Surveyor asked LPN I if the nurse is expected to assess the skin with the CNA on bath day. LPN I stated no, only the CNAs do it.
Surveyor asked LPN I if nurses are expected to complete a weekly skin assessment. LPN I stated no, unless the CNA reports a concern.
Surveyor asked LPN I if the nurse reviews the completed weekly bath sheets. LPN I stated no, not unless the CNA says there is a concern.On 05/27/26 at 11:55 AM, Surveyor interviewed Clinical Nurse Manager (CNM) J regarding skin assessments and preventative measures for breakdown. CNM J stated the expectation would be for nurses to document at least weekly on skin condition after the bath sheet is completed.
Surveyor asked CNM J if anyone is reviewing or monitoring if the weekly skin checks are documented or if the bath sheets are completed. CNM J stated no.
Surveyor asked CNM J how staff document when residents are repositioned or if incontinence briefs are checked/changed. CNM J stated there is no current practice in place for staff to document this, but staff are expected to turn and reposition residents frequently.
Surveyor asked CNM J how they monitor residents at risk for PIs or currently have PIs are being turned and repositioned frequently. CNM J stated no process is currently in place to do this.On 05/27/26 at 12:01 PM, Surveyor interviewed Wound Nurse C regarding the additional resource for PIs.
Wound Nurse C stated that this resource is a wound specialty provider that comes onsite monthly to review residents with PIs and other skin issues.
Surveyor asked Wound Nurse C if this resource was contacted regarding R1.
Wound Nurse C stated no.
525706 05/27/2026
Christian Community Home of Osceola, Inc 2650 65th Ave Osceola, WI 54020
reviewed fall and determined root cause to be R4 being up at 8:00 PM and self-transferred.
New
Nursing (DON) B and Clinical Nurse Manager (CNM) J regarding R4's falls. DON B stated all the
asked DON B and CNM J how they ensure interventions are in place and effective.
Both DON B and CNM J were unable to provide an answer.
Surveyor asked DON B and CNM J if there was any documentation of staff completing 2-hour checks as stated in care plan. CNM J stated no.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.