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 REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Christian Home LLC
452 Fox Lake Road Waupun, WI 53963
SUMMARY STATEMENT OF DEFICIENCIES
findings to the physician, DON B stated yes.
Cross reference F-F692
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Christian Home LLC
452 Fox Lake Road Waupun, WI 53963
SUMMARY STATEMENT OF DEFICIENCIES
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 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Christian Home LLC
452 Fox Lake Road Waupun, WI 53963
SUMMARY STATEMENT OF DEFICIENCIES
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.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.
Facility ID: