Complete Care at Christian Home LLC
452 Fox Lake Road, Waupun, WI 53963 · Dodge County · 50 certified beds · avg 37 residents/day · certified since May 1, 1994
Part of chain: COMPLETE CARE (85 facilities, chain avg rating 3.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 15, 2026 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 8, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 15, 2026 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 8, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 7, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 7, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (12)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 15, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 15, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 15, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Oct 14, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 14, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 14, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 14, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Nov 22, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2025 | 6 | 2 | G ▲ |
| 2026 | 5 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.58 | 4.29 | 3.95 | top 33% in Wisconsin; top 21% in the U.S. |
| Registered Nurse hours | 1.31 | 1.01 | 0.69 | top 19% in Wisconsin; top 7% in the U.S. |
| Weekend total nurse staffing | 4.24 | 3.84 | 3.50 | top 30% in Wisconsin; top 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.01 | 0.68 | 0.48 | top 12% in Wisconsin; top 6% in the U.S. |
| Total nursing staff turnover (%) | 66.1 | 46.9 | 45.8 | bottom 10% in Wisconsin; bottom 9% in the U.S. |
| RN turnover (%) | 66.7 | 39.7 | 42.9 | bottom 11% in Wisconsin; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.66, RN 1.33, weekend 4.32. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Klugman, Jacob | Individual | Indirect Ownership Interest | NOT APPLICABLE | 02/28/2025 |
| PC WCM Opco Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/28/2025 |
| PC WCM Topco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/28/2025 |
| Peace Capital Holdings II LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/28/2025 |
| SMS 2021 Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 02/28/2025 |
| Stein, Shalom | Individual | Indirect Ownership Interest | NOT APPLICABLE | 02/28/2025 |
| Christian Home Propco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Des Capital LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Fentrow, Lauren | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
| Fentrow, Lauren | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Hellman, Yosef | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/28/2025 |
| Hellman, Yosef | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
| JRK Investments LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Klugman, Jacob | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Larson, Cindy | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/28/2025 |
| Larson, Cindy | Individual | ADP of the SNF | NOT APPLICABLE | 03/28/2025 |
| Leverentz, Luanne | Individual | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| PC WCM Propco Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| PC WCM Topco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
| Peace Capital Holdings II LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/28/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Hillside Manor | 13.0 mi | Beaver Dam, WI | ★★☆☆☆ | 2/5 | |
| Beaver Dam Health Care Center | 13.2 mi | Beaver Dam, WI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Markesan Resident Home | 13.2 mi | Markesan, WI | ★★★★★ | 5/5 | |
| Avina of Mayville | 13.8 mi | Mayville, WI | ★★★☆☆ | 3/5 | |
| Randolph Health Services | 14.1 mi | Randolph, WI | ★★★☆☆ | 3/5 | |
| Hope Health and Rehab | 16.2 mi | Lomira, WI | ★★★★★ | 4/5 | |
| Whispering Pines Nursing and Rehab, LLC | 16.3 mi | Ripon, WI | ★★★☆☆ | 3/5 | |
| Clearview | 16.5 mi | Juneau, WI | ★★★★★ | 4/5 | |
| Clearview Brain Injury Center | 16.5 mi | Juneau, WI | ★★★★★ | 5/5 | |
| Fond Du Lac Lutheran Home | 18.8 mi | Fond Du Lac, WI | ★★★☆☆ | 3/5 | |
| Avina of Fond Du Lac | 19.1 mi | Fond Du Lac, WI | ★★☆☆☆ | 2/5 | |
| St Francis Home | 19.1 mi | Fond Du Lac, WI | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525531.