Map showing the location of Complete Care at Christian Home LLC in Waupun, Wisconsin
452 Fox Lake Road, Waupun, WI, 53963

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinAbove only 42% of peers321 rated homes · average 3.0★
  • Dodge CountyAbove only 44% of peers10 rated homes · average 2.8★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs WI avg
  • StaffingCan add or remove a star4★+0.3 vs WI avg
  • Quality measuresCan add or remove a star2★−1.1 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Ownership changed in the last 12 monthsRatings reflect performance under previous and current owners. Ask how staffing and management changed after the sale.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 44% of peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 35% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 8% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.02hrsAbove 87% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.33hrsAbove 88% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better54%Above only 31% of peersWI avg48%RN turnover46%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 42% of peersWI avg$41,875Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
13citations
5inspection dates
2actual harm (G–I)
0immediate jeopardy (J–L)
Oct 14, 2025most recent

Citations by monthOct 2022 – Oct 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Oct 14, 20254 citationsCycle 1worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 7, 2025
  2. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Nov 7, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Nov 7, 2025
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 7, 2025
Jan 30, 20252 citationsCycle 1worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 21, 2025
  2. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Feb 21, 2025
Nov 22, 20231 citationCycle 2worst D · no actual harm
  1. F585Honor 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.Resident RightsD · isolatedCorrected Dec 21, 2023
Feb 28, 20234 citationsCycle 3worst D · no actual harm
  1. F585Honor 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.Resident RightsD · isolatedCorrected Mar 26, 2023
  2. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 26, 2023
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 26, 2023
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 26, 2023
Oct 19, 20222 citationsCycle 3worst E · no actual harm
  1. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Nov 14, 2022
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 14, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.02hrsAbove 87% of peers+0.83 vs WI avg
  • Registered nursesRN hours only1.33hrsAbove 88% of peers+0.37 vs WI avg
  • Licensed practical nursesLPN hours1.03hrs
  • Nurse aidesCNA hours2.66hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.47hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better54%Above only 31% of peersWI avg 48%
  • RN turnoverRegistered nurses only46%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy50 certified beds · ~32 residents a day64%Above only 29% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $41,875WI avg in fines
Above only 42% of peersFewer fines than 42% of rated homes in Wisconsin

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Wisconsin facilities average 1.2 penalties.

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Complete Care85 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
Changed hands in the last 12 months

People and entities on file

Direct owners (5%+)
  • Pc Wcm Opco Holdco LLC
Indirect owners (5%+)
  • Pc Wcm Topco LLC
  • Peace Capital Holdings II LLC
  • Sms 2021 Trust
Operational or managerial control
  • Lauren Fentrow
  • Yosef Helman
  • Cindy Larson
  • Daniel Sternbuch
  • Lisa Weber
Corporate officers
  • Shalom Stein

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525531 · 452 Fox Lake Road, Waupun, WI, 53963.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Dodge County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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