Cycle 1
Health 2025-01-30 · Fire 2025-01-30
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Waupun, WI
Complete Care at Christian Home LLC
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
452 Fox Lake Road, Waupun, WI
(920) 324-9051
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1994-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.33
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.02
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.47
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.06
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.30
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,123
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0060
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.50
Performance 20.27% · Measure score 2.50 · Achievement 2.50 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.51
Performance 5.89% · Measure score 6.51 · Achievement 6.51 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.17
Baseline 44.23% · Performance 38.46% · Measure score 6.17 · Achievement 6.17 · Improvement 2.48
Adjusted total nurse staffing
5.47
Baseline 4.38 hours · Performance 4.63 hours · Measure score 5.47 · Achievement 5.47 · Improvement 1.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 7.11% |
| Discharge to community | 51.53% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 47.27% · Lower 95% interval 40.97% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 5.89% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 0% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 2.6% |
8.2%
5.6 pts worse
|
Numerator 4 · Denominator 154 |
| Staff flu vaccination coverage | 87.9% |
42%
45.9 pts better
|
Numerator 138 · Denominator 157 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
95.7%
2.2 pts worse
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · Q4 80.0% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.2%
3.3 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q4 5.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
5.0%
3.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
16.6%
6 pts worse
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.1% |
16.7%
6.4 pts worse
|
16.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.5% |
21.1%
18.4 pts worse
|
16.3%
23.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
17.3%
5.8 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.6% |
25.5%
8.1 pts worse
|
19.8%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.6% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.5%
2.7 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 7.0% · Q4 10.7% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.1% |
86.8%
14.7 pts worse
|
81.7%
9.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 85.7% · Q3 65.5% · Q4 44.0% · 4Q avg 72.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
15.0%
7.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
82.2%
0.3 pts better
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
22.7%
4.7 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 25.0% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-22 · Fire 2023-11-22
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-10-19 · Fire 2022-10-19
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
E · Potential for more than minimal harm
2025-01-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-01-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-01-30
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-01-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-14
F · Potential for more than minimal harm
2023-11-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
F · Potential for more than minimal harm
2023-11-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-11-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-21
F · Potential for more than minimal harm
2022-10-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
E · Potential for more than minimal harm
2022-10-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-11-09
E · Potential for more than minimal harm
2022-10-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-10-26
E · Potential for more than minimal harm
2022-10-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-09
D · Potential for more than minimal harm
2022-10-19
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-11-09
D · Potential for more than minimal harm
2022-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-10-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-09
Inspection history
Recent health citations
G · Actual harm
2025-10-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-07
G · Actual harm
2025-10-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-10-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-10-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-01-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-21
D · Potential for more than minimal harm
2023-11-22
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-21
E · Potential for more than minimal harm
2022-10-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-14
Penalties and ownership
What sits behind the stars
Ownership
Pc Wcm Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Fentrow, Lauren
Operational/Managerial Control · Individual
Helman, Yosef
Operational/Managerial Control · Individual
Larson, Cindy
Operational/Managerial Control · Individual
Pc Wcm Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Sternbuch, Daniel
Operational/Managerial Control · Individual
Weber, Lisa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hillside Manor
Beaver Dam, WI
3-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Beaver Dam Health Care Center
Beaver Dam, WI
1-star overall rating with 1-star inspections with abuse icon flag with $144,764 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Markesan Resident Home
Markesan, WI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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