Complete Care At Christian Home Llc

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility did not complete a thorough investigation in response to a potential allegation of abuse for 1 of 3 Residents (Resident R1) reviewed for abuse.On 10/1/25, the facility became aware of

an alleged injury of unknown origin due to Resident R1's subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull). The facility did not complete a thorough investigation.Evidenced by:The facility's Injuries of Unknown Source policy, dated 2/2025, states, in part: All unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.7. An injury of unknown source shall be investigated even if the resident is discharged from the facility as a result of an injury, or an injury of unknown source is identified after discharge.Resident R1 admitted to the facility on [DATE REDACTED] with diagnoses including cognitive communication deficit (a difficulty with communication caused by problems with the brain's thinking ability); repeated falls; difficulty in walking; muscle wasting and atrophy (a condition where muscles lose mass and strength).Resident R1's Brief Interview for Mental Status, dated 9/26/25, had

a score of 9, indicating Resident R1 is moderately cognitively impaired.A facility self-report indicates on 10/1/25 the facility learned that Resident R1 was found to have a subdural hematoma.On 10/14/25 at 7:49 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about the self-report for Resident R1. NHA A stated the facility looked at the situation as an injury of unknown origin as they did not know how the subdural hematoma occurred. NHA A stated that DON B started getting statements from staff. Surveyor requested

the statements from staff. No staff statements were provided. Surveyor asked NHA A if staff statements are expected. NHA A stated, yes, statements are a part of a thorough investigation. NHA A stated that staff education was started on falls prevention as part of a process improvement project (PIP) initiated following

this incident. Pre/Post Tests from the education were provided to surveyor for 21 staff members. Surveyor asked if there was training provided for the other 19 staff members who have worked between starting the training to the present. NHA A stated no, there was no additional documentation of training yet. NHA A stated that the facility was planning for additional training as they worked through their PIP, but it had not yet occurred. Surveyor asked if all staff should have the training. NHA A stated yes.On 10/14/25 at 12:32 PM, Surveyor interviewed DON B who stated that staff were talked to about the subdural hematoma, but no written statements were obtained. The facility failed to complete a thorough investigation for an injury of unknown origin.

Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Christian Home LLC

452 Fox Lake Road Waupun, WI 53963

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

findings to the physician, DON B stated yes. Cross reference F-F692

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Christian Home LLC

452 Fox Lake Road Waupun, WI 53963

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

pupils, and cognition. RN I indicated an incident report has to be completed. RN I stated there are a couple of assessments that are triggered when an incident report is completed including the Post Fall Assessment.

RN I indicated the incident report helps to identify the root cause and interventions should be put in place

after a resident falls. RN I indicated the resident needs documented follow up 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 Resident R1's care plan together. LPN J indicated Resident 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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Christian Home LLC

452 Fox Lake Road Waupun, WI 53963

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

applicable 10/11/25: 50 cc, not applicable10/12/25: 0cc, not applicableOn 10/14/25 at 9:34 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C who is responsible for monitoring resident's fluid intakes, RN C stated that they only monitor fluid intakes if the resident is on a fluid restriction, otherwise no one is monitoring fluid intakes. Surveyor asked RN C how staff knows if a resident is at risk for dehydration, RN C stated that if a resident is not drinking, then they are at risk. Surveyor asked RN C if residents' care plans or Kardex's indicate if they are at risk for dehydration, RN C stated that she did not know.On 10/14/25 at 1:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how staff know if a resident is at risk for dehydration, DON B stated that all residents are at risk for dehydration. Surveyor asked DON B who is responsible for ensuring that residents are receiving adequate fluids, DON B stated that the dietician is responsible for monitoring the fluid intakes, but they will look at it if

they notice a change in the resident's intake or urine. Surveyor asked DON B if the dietician recommends a resident receive 2350 cc of fluids per day, who is ensuring that the resident is meeting their goal, DON B was not sure.Resident R2's fluid intakes were not monitored to ensure he was meeting his estimated daily fluid needs, resulting in Resident R2 being hospitalized for dehydration.Cross reference F-F684.

Event ID:

Facility ID:

If continuation sheet