Complete Care At Christian Home Llc
Complete Care at Christian Home LLC in Waupun, WI — inspection on October 14, 2025.
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
The facility failed to complete a thorough investigation for an injury of unknown origin.
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
525531 10/14/2025
Complete Care at Christian Home LLC 452 Fox Lake Road Waupun, WI 53963
was not responding. CNA D then told Surveyor that when the second shift came on duty, she reported
reported that typically R2 is a pivot assist to transfer, and on this day, they were having to use an EZ
(Licensed Practical Nurse).
Surveyor asked LPN E about the events of 10/6/25 and R2. LPN E stated that she worked 2nd shift that day and that during report, RN C stated that R2 had altered mental status and wasn't acting like himself. LPN E reported that she asked RN C if she assessed R2, took vital signs, or updated the doctor, and RN C stated no, he's fine. LPN E stated that the CNA wasn't comfortable transferring R2 and asked her for assistance. LPN E went to R2's room and noted that he did not look right and proceeded to check vital signs and complete an assessment. LPN E also reported to Surveyor that CNA D stated that R2 was having a change of condition over the weekend as well.On 10/14/25 at 9:34 AM, Surveyor interviewed RN C (Registered Nurse).
Surveyor asked RN C to explain R2's change in condition on 10/6/25. RN C stated that R2 wasn't opening his eyes, was not giving verbal responses, and had increased shaking. RN C stated that the CNA reported R2's condition to her and that R2's wife was concerned. RN C stated that she asked R2 how he was, and he said ok, and asked him if he was cold, and he said no. RN C stated that R2 took his morning medications, but he was unable to swallow his noon medications, and that she tried ten times to give it to him. RN C reported that R2's head was tipped down and he was unable to get his lips to go around the spoon. RN C reported that after she checked on R2 at breakfast, she reported R2's condition to DON B.
Surveyor asked RN C what directives were given by DON B. RN C stated that she was told that R2 was probably having a Parkinson's flare up. RN C stated that she asked the physician to look at R2 because he was not looking good and was having increased shaking.
Surveyor asked RN C if the physician assessed R2. RN C stated that she was unsure, and that the physician ordered labs.
Surveyor asked RN C if she completed any kind of assessment on R2. RN C stated that she just talked to him and that she could have obtained R2's vital signs, but she didn't.
Surveyor asked RN C if documentation should be completed timely, RN C stated yes.On 10/14/25 at 1:04 PM, Surveyor interviewed MD H (Medical Doctor).
Surveyor asked MD H if RN C reported R2's change of condition to her while she was in the building on 10/6/25, MD H stated no. MD H stated that the CNA came up to her and said that the nurse wanted her to look at R2 and reported that he was weaker. MD H stated that she saw R2 earlier in the morning when she was visiting his wife and that he seemed ok.
Surveyor asked MD H if she would have expected RN C to complete an assessment, obtain vital signs, and report them to you, MD H stated yes.On 10/14/25 at 1:25 PM, Surveyor interviewed DON B.
Surveyor asked DON B when she was made aware of R2's change of condition? DON B stated that RN C had reported that R2 had increased shaking, and I told her to let the physician know.
Surveyor asked DON B what the expectation is for nurses when a resident is noted to have a change of condition? DON B stated that they should assess the resident, check vital signs, and contact the physician.
Surveyor asked DON B if RN C should have completed an assessment on R2 and reported the findings to the physician, DON B stated yes.
Cross reference F-F692
525531 10/14/2025
Complete Care at Christian Home LLC 452 Fox Lake Road Waupun, WI 53963
cognition. RN I indicated an incident report has to be completed. RN I stated there are a couple of
Assessment. RN I indicated the incident report helps to identify the root cause and interventions
every shift for 72 hours after a fall.
On 10/14/25 at 1:46 PM, Surveyor interviewed LPN J regarding care plans. LPN J stated she is responsible for updating resident care plans when she completes the MDS (Minimum Data Set) assessment. LPN J indicated she also updates the care plans after the IDT meetings in the morning.
LPN J indicated she does update care plans with fall interventions that were discussed in the morning IDT meeting. LPN J indicated the care plans should be updated as soon as possible with new information.
Surveyor and LPN J reviewed R1's care plan together. LPN J indicated R1's care plan had not been updated related to any of his 7 documented falls. LPN J indicated if she does not attend the IDT meeting in the morning or is not made aware of new interventions she would not know the care plan needed to be updated.
Surveyor asked what the process was for updating the care plans when LP
525531 10/14/2025
Complete Care at Christian Home LLC 452 Fox Lake Road Waupun, WI 53963
asked DON B how staff know if a resident is at risk for dehydration, DON B stated that all residents
intakes, but they will look at it if they notice a change in the resident's intake or urine.
Surveyor
that the resident is meeting their goal, DON B was not sure.R2's fluid intakes were not monitored to ensure he was meeting his estimated daily fluid needs, resulting in R2 being hospitalized for dehydration.Cross reference F-F684.
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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.