Citations in Wisconsin
Statistics, citations and compliance trends for long-term care facilities in Wisconsin.
Statistics for Wisconsin (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Wisconsin
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Latest Citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Provided training to nursing staff on supervision requirements and sexual behaviors requiring close monitoring, with emphasis on monitoring near vulnerable individuals (J - F0600 - WI)
- Reinforced use of the Kardex every shift and CNA review of the binder for resident-care changes to support consistent communication of supervision needs (J - F0600 - WI)
- Prohibited agency staff from being assigned to the resident’s hallway to reduce supervision/communication gaps (J - F0600 - WI)
- Completed education with the staffing coordinator, nursing leadership, Human Resources, and the NHA on staffing expectations to ensure staffing requirements were followed (J - F0600 - WI)
- Implemented documentation of 1:1 supervision every shift to support accountability for required supervision (J - F0600 - WI)
- Educated the IDT to ensure non-verbal residents were not placed on the resident’s hallway to reduce exposure of highly vulnerable residents (J - F0600 - WI)
- Implemented daily audits to ensure 1:1 supervision was completed and documented (J - F0600 - WI)
- Implemented daily audits to ensure the hallway did not have agency staff scheduled, and required documentation that any unavoidable agency staff were educated (J - F0600 - WI)
Failure to Supervise Resident With Known Sexual Behaviors Resulting in Sexual Abuse of a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident with known sexually inappropriate behaviors. One resident (R2) had a documented history of making sexual comments, attempting to touch staff’s buttocks, and inappropriately touching female residents, including a prior incident of grabbing a female resident’s chest and using vulgar language toward staff and residents. R2’s comprehensive care plan specified that he must be escorted to and from activities, kept at least an arm’s length away from all female residents, monitored when in common areas, and kept out of arm’s reach from female residents. Staff interviews confirmed that, prior to the incident, R2 was to be in staff line of sight whenever out of his room and not left around female residents. The victim, R1, was a severely cognitively impaired, nonverbal resident with autism and metabolic encephalopathy, identified in her care plan as vulnerable due to limited speech and inability to call out for help or remove herself from unsafe situations. Her care plan included the need to provide a safe environment. On the date of the incident, R2 was observed in a lounge area with R1, with his hand on her in a way that appeared to be touching her private area. A CNA reported seeing R2 touching R1 in the abdomen area when returning from putting trays on the cart. Staff immediately separated the two residents and notified the RN on duty. Interviews and record review showed that R2 was left unsupervised in the lounge with R1 despite his care plan requirements for close supervision and restrictions around female residents. The CNA involved, who was agency staff, later reported she believed R2’s extra supervision was required only during mealtimes, indicating that she did not follow or was not aware of the full supervision requirements outlined in R2’s care plan and Kardex. The surveyors determined that the facility failed to provide adequate supervision and to follow R2’s care plan interventions to keep him out of arm’s reach of female residents and under monitoring in common areas, resulting in an incident of sexual touching of a nonverbal, severely cognitively impaired resident who could not consent or protect herself. This failure led to a finding of immediate jeopardy beginning on the date of the incident.
Removal Plan
- Separated R2 and R1
- Placed R2 on 1:1 staffing
- Completed a full head-to-toe assessment for R1
- Placed CNA G on administrative leave
- Ensured all residents in the facility were safe and expressed no concerns regarding safety
- Notified police, guardians, state agency, and Medical Director
- Sought Behavioral Care for R2 to review medications and increased sexual behavior
- Sent R1 to the emergency room for evaluation (no new orders)
- Provided training to nursing staff on supervision requirements and sexual behaviors requiring close monitoring, especially near vulnerable individuals
- Reinforced use of the Kardex every shift and CNA review of the binder for any additional changes to resident care
- Prohibited agency staff from being assigned to R2's hallway
- Completed education with staffing coordinator, nursing leadership, Human Resources, and NHA to ensure staffing expectations are followed
- Implemented documentation of 1:1 supervision every shift
- Educated the IDT to ensure non-verbal residents will not be placed on R2's hallway
- Implemented daily audits to ensure 1:1 is being done and documented
- Implemented daily audits to ensure R2's hallway does not have agency staff scheduled; if unavoidable, require documentation that the agency employee was educated
Failure to Reassess Smoking Safety After Resident-Initiated Fire
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who smoked and possessed smoking materials. The resident had multiple mental health and behavioral diagnoses, including alcohol use, generalized anxiety disorder, cocaine abuse, major depressive disorder, PTSD, and a history of restlessness, agitation, hoarding, verbal aggression, and threats toward staff. Her care plan documented that she chose to safeguard her own smoking materials in her room, was expected to adhere to the facility’s tobacco/smoking policy, and had been assessed as cognitively intact with a BIMS score of 15. The facility’s written smoking policy required that cigarettes, lighters, matches, and all tobacco products be turned in to the nurse for secure storage, prohibited smoking materials in resident rooms or on their person, and required smoking safety assessments quarterly and as needed with any change in condition or functional abilities. On the morning of 2/27/26, staff detected the smell of smoke on the resident’s hallway. An LPN reported smelling smoke while assisting another resident and directed CNAs to search rooms. CNAs discovered a wet, burned pile of ace wrap and sheet pieces on the floor of the resident’s room, several steps in front of the sink, with no active flames. The resident was not in the room at that moment but admitted to staff that she had started the fire, with one CNA reporting that the resident stated she did it on purpose and said, “We are all going to die anyways.” Staff also reported finding a knife, medications, and another item in the resident’s belongings and turning these over to the administrator. Nursing documentation noted that the resident had cut up an ace wrap and sheet and started the material on fire, that she stated she was not in her right mind and did not know why she started the fire, and that the administrator was updated. The administrator documented that staff notified him that the resident had ignited a small item in her room using a personal lighter, that he met with the resident, and that she reported burning something small near her shoe. He removed the lighter, initiated 15‑minute safety checks, and requested a review of her mental status and cognition. The resident’s care plan was updated the same day to add that she sometimes had behaviors including attempting to start a fire with her lighter, with interventions such as monitoring for danger to self or others and contacting law enforcement/administrator if the behavior recurred. However, the facility did not complete an updated Smoking and Safety Assessment immediately after the fire incident, despite the policy requirement for reassessment with changes in condition or functional abilities. Staff interviews indicated that after the incident the resident continued to have smoking materials, managed them on her own, and went in and out to smoke, while the receptionist and nursing staff reported they had not been instructed to secure her smoking materials and that she continued to safeguard them in her room lockbox. A later Smoking and Safety Assessment completed on 3/4/26, after surveyor inquiry, did not document the prior fire, did not mark burned items as a concern, and stated there were no concerns with her ability to smoke safely outside, demonstrating that the facility failed to reassess and revise her smoking safety status in response to the fire she started in her room. The surveyors determined that the facility’s failure to reassess the resident’s safety with smoking materials after she started a fire in her bedroom, and the continued care planning and allowance for her to have smoking materials on hand, constituted a failure to identify and address the risk. The facility’s own policy prohibited smoking materials in resident rooms and required secure storage and reassessment with changes in condition, yet the resident’s care plan and staff accounts showed she retained access to smoking materials and a lockbox in her room. The facility leadership stated they viewed the incident as related to mental health and not unsafe smoking, and initially did not redo the smoking assessment because they did not consider smoking itself to be the concern. These actions and inactions led to a finding of immediate jeopardy beginning on 2/27/26, later reduced to a deficiency at scope/severity level E as the facility continued to implement its action plan.
Removal Plan
- All staff re-educated on the facility's non-smoking policy prior to their next shift, including that smoking is not permitted inside the building and that smoking materials such as lighters, matches, and cigarettes must be stored at the nurse station or in an approved resident lockbox per facility policy.
- A facility wide audit was conducted to ensure residents do not possess ignition sources or weapons, and any items identified were immediately secured according to facility policy.
- All residents who smoke or possess smoking materials are being provided with a new smoking safety assessment.
- Staff were educated that any resident demonstrating unsafe behavior with smoking materials will have materials secured and will receive an immediate reassessment, with care plan interventions implemented as appropriate.
- Residents who smoke were educated regarding not using smoking materials in the facility and fire safety.
- The resident involved in the incident had smoking materials secured by staff, was reassessed for safety, and care plan interventions were updated.
- The facility generated a comprehensive list of all residents who expressed desire to smoke and completed a smoking evaluation for each identified resident along with care plan revisions.
- The facility reviewed the smoking policy and expectations regarding possession of weapons.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks on residents who smoke to ensure smoking is done safely, lighters/ignition materials are being kept appropriately or not in possession of those who are unsafe to have them, policy is followed, assessments are completed, and care plans are in place.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks of staff to ensure they know the proper procedures on what to do if a resident has a weapon.
- Administrator or designee will conduct random audits 4 times weekly for 8 weeks to ensure residents are free of weapons.
- Results of audits will be reviewed at QAPI for further recommendations.
Failure to Supervise High-Risk Wanderer With Repeated WanderGuard Removal
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring for a resident with a known history of elopement and WanderGuard (WG) removal. The resident had diagnoses including dementia, seizure disorder, schizoaffective disorder, and bipolar disorder, and a protective placement document on file requiring placement on a secured unit due to prior absconding attempts and inability to assure safety on an unsecured unit. The resident’s care plan identified elopement and wandering risk, with interventions such as WG placement, monitoring/documenting wandering episodes and triggers, and adding the resident to an elopement risk list. Despite this, an initial elopement risk assessment rated the resident as low risk, later revised to at risk and then high risk, and the facility did not consistently increase supervision or monitoring in response to repeated elopement attempts and WG removals. Over several weeks, the resident repeatedly attempted or succeeded in leaving the facility or its immediate grounds. On multiple occasions, staff documented the resident walking up and down hallways with belongings piled on a wheelchair, locking in a guest restroom with personal items, and exiting to the front of the building or parking lot, sometimes in cold weather and without appropriate clothing. The resident cut off the WG on several dates, and staff reapplied new WGs but did not implement increased supervision or more frequent WG checks, nor did they determine or address how the resident was obtaining tools (such as scissors) or otherwise removing the device. The facility placed a WG on the resident’s wheelchair despite knowing the resident historically cut off the WG and despite manufacturer recommendations discouraging placement near metal due to interference with radio frequency. Staff also did not consistently implement individualized interventions listed in the care plan, such as offering to take the resident outside, engaging in conversations about religion or crafts, or checking daily for needed items from outside the facility. On one occasion, the resident left the building without a walker or wheelchair, attempted to get into a visitor’s vehicle, and was brought back inside after staff were alerted by the visitor; the WG had been cut off and was later found on a unit. On another occasion, the resident exited the facility, and staff and police were unable to redirect the resident back inside immediately. The most serious event occurred when the resident was last seen in the dining room and later could not be found during rounds; staff initiated a search and located the resident in the bathroom of a nearby business across a busy street, in cold and dark conditions, after the resident had cut off the WG and hidden it in the lobby. The facility’s own investigation acknowledged that the door alarm did not sound because the WG had been removed and hidden, and that the facility could have potentially failed to keep the resident safe. Review of treatment administration records showed multiple shifts with missing documentation of required WG placement and function checks, and a gap of several days with no documented WG checks after the resident returned from the hospital. Facility leadership acknowledged that they did not attempt to increase supervision or WG checks despite multiple elopement attempts and WG removals, and staff interviews confirmed that individualized wandering and elopement interventions were not consistently carried out. These failures led to a finding of immediate jeopardy beginning on 11/6/25.
Removal Plan
- Reviewed and revised care plans for all residents who display exit seeking behavior and/or scored at risk on their Elopement Risk Assessment.
- Reviewed the facility's Elopement Risk and Prevention policy and procedure to ensure it meets current standards of practice.
- Educated staff on ensuring each resident receives adequate supervision and assistive devices to prevent accidents; the facility's Elopement Risk and Prevention policy; how to properly respond and interventions to put in place if a resident exit seeks, leaves the facility, removes a WG, or searches for or is provided tools to remove a WG.
- Implemented elopement audits and elopement drills.
- Reviewed and updated the Facility Assessment.
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