B-
70/100Complete Care at Christian Home LLC Inspection Report, Violations & Safety Grade (Waupun, Wisconsin)
452 Fox Lake Road, Waupun, Wisconsin 53963
Phone: 9203249051
CMS Overall:2/5
Overview & Bed Count
Certified Beds
50
Avg Residents/Day
37.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Dodge
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing4/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.05 | 0.98 | +0.06 |
| Total Nurse Hours per Resident per Day | 4.69 | 4.25 | +0.44 |
| CMS Staffing Rating | 4/5 | 3.7/5 | - |
| Nursing Staff Turnover | 60.3% | 46.7% | - |
Health Citation History
12 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-15 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2026-04-15 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2026-04-15 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2026-04-15 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-04-15 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2025-10-14 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2025-10-14 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-10-14 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-10-14 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2025-01-30 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-01-30 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2023-11-22 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
Fire Safety Citation History
16 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-04-15 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2026-04-15 | Egress Deficiencies | Have exits that are accessible at all times. | E – Moderate Harm Potential |
| 2026-04-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2026-04-15 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | C – Minimal Harm Potential |
| 2025-01-30 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2025-01-30 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2025-01-30 | Egress Deficiencies | Have exits that are accessible at all times. | E – Moderate Harm Potential |
| 2025-01-30 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2025-01-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | E – Moderate Harm Potential |
| 2025-01-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2025-01-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate Harm Potential |
| 2023-11-22 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2023-11-22 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2023-11-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2023-11-22 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2023-11-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Waupun area at no cost.
Find Safe, Vetted Facilities Near Waupun
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.