Complete Care at Christian Home LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Christian Home LLC, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 15, 2026

  Based on observation, interview, and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 3 of 5 residents (R5, R4, and R2) reviewed. R5 developed a blister to their right heel. The facility failed to complete diabetic foot checks, complete a full wound assessment, and update the physician timely. The facility failed to ensure proper skin assessment and wound measurements were completed at the time of admission for R2 R4 complained of not feeling well and had an emesis. Facility did not perform an assessment. […]

• Actual harm, isolatedF686Apr 15, 2026

  Based on observation, interview, and record review, the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development or worsening of PIs for 1 of 2 residents (R5) reviewed for pressure injuries.R5 was admitted to the facility with a cervical collar. The facility failed to complete skin assessments and R5 developed an unstageable pressure injury from his cervical collar. RN H (Registered Nurse) was observed not follow physician orders during treatment observation. […]

• Actual harm, isolatedF684Oct 14, 2025

  Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 residents (R2) reviewed.R2 had a noted change in condition by RN C (Registered Nurse). RN C failed to perform an assessment, check vital signs, and provide an accurate assessment to the physician. R2 continued to decline and was eventually sent to the ED (Emergency Department) where he received treatment for hypothermia and IV (intravenous) fluids.Evidenced by:Surveyor requested the facilities Change in Condition policy; no policy was provided. […]

• Actual harm, isolatedF689Oct 14, 2025

  Based on interview and record review, the facility did not ensure that each resident receives adequate supervision to prevent accidents for 2 of 3 residents (R1 and R3) reviewed for falls. R1 had 7 unwitnessed falls while self-transferring. The facility failed to complete adequate assessments, conduct root cause analyses, and implement interventions to address the unsafe self-transferring. R1 was found to have a subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull). R3 was admitted to the facility on [DATE] and identified at risk for falls. R3 has had 8 falls since the time of admission to current. […]

• Actual harm, isolatedF610May 20, 2021

  Based on record review and interview, the facility did not ensure all allegations of abuse/mistreatment were thoroughly investigated for 1 Resident (R) (R1) of 4 residents and that measures were put in place to prevent further potential abuse/mistreatment while an investigation was in progress. Multiple staff witnessed and reported FLPN (Former Licensed Practical Nurse)-L used one finger, multiple fingers or an entire hand to remove stool from R1's rectum. Staff reported R1 expressed discomfort with the procedure and asked FLPN-L to stop. Staff also reported R1 became increasingly anxious prior to care, during care and when getting into bed as a result of FLPN-L's actions. […]