Complete Care at Christian Home LLC

Inspectors wroteBased 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. R4 was hospitalized the following day due to noted change of condition and admitted with urinary tract infection. Evidenced by: The article Diabetic foot ulcer: [...]

Inspectors wroteBased 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. Evidenced by: The American Medical Directors Association (AMDA) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: [...]

Inspectors wroteBased on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect all 34 residents who reside at the facility. The facility had tests that were positive for Legionella. The facility did not have water heater temperatures adequate to kill Legionella, did not provide interventions for R22's room to mitigate risk of exposure for R22, and did not do additional testing to ensure effectiveness of control measures taken in the building. Evidenced by:Per the CDC (Center for Disease Control and Prevention) page entitled Controlling legionella in potable water systems, indicates the following: Operation, maintenance, and control limits . Guidance . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 12 residents (R3) reviewed for grooming. R3 verbalized wish to be clean shaven and was observed with facial hair for three consecutive days. Evidenced by:The facility's Grooming a Resident's Facial Hair policy, dated 2/26, states, in part: It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. Important to note: the policy does not indicate how often shaving is to occur. On 4/13/26 at 10:25 AM, Surveyor interviewed R3 during initial screening. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 25 opportunities that affected 2 out of 8 residents (R14 & R1) included in the medication administration task, which resulted in an error rate of 8%. Surveyor observed RN E (Registered Nurse) prepare to crush R14's Pantoprazole DR (delayed release; a medication used to reduce stomach acid) to administer it to R14 before Surveyor stopped her. Surveyor observed RN D (Registered Nurse) did not prime R1's insulin pen before administration and did not keep the needle in the skin after administration to ensure proper dosing. This is evidenced by: The facility policy, Administering Medications, updated 10/2022, states in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased 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. AMDA (American Medical Directors Association) guidelines, 2003, states, in part: [...]

Inspectors wroteBased 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. The facility failed to identify root causes of the falls, identify trends, and update care plan. This is evidenced by: The facility policy Fall Prevention Program, dated 2/28/25, includes: [...]

Inspectors wroteBased 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 (R1) reviewed for abuse. On 10/1/25, the facility became aware of an alleged injury of unknown origin due to 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. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 3 residents (R2) reviewed for hydration. R2's fluid intakes were not monitored to ensure he was meeting his estimated daily fluid needs, resulting in R2 being hospitalized for dehydration. Evidenced by:The facility's policy titled Nutritional Management dated 2/2025 states in part .3. Evaluation/ analysis: a. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/ hydration. b. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 3 residents (R17) reviewed for change in condition. R17 had a significant weight loss that was not reported to R17's provider timely. R17 had a change in condition on 11/24/24 that was not reported to R17's provider timely. This is evidenced by: The facility's Notification of Change policy, dated 1/2025, states, in part: The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for 1 of 5 residents (R23) reviewed for unnecessary medications. R23 receives an antidepressant for sleep without an appropriate diagnosis. R23 did not have a sleep assessment conducted prior to medication administration. This is evidenced by: The facility policy entitled, Psychotropic Medication dated 5/2020, states, in part: .1. The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. The medical record must show documentation of adequate indication and diagnosed condition . 2. [...]

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure a grievance was documented, thoroughly investigated, and resolved for 1 Resident (R) (R11) of 15 sampled residents. The facility did not document, investigate and resolve R11's grievance regarding a pair of missing pants.