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)
Latest citations in Wisconsin
A resident with severe dementia and repeated falls had inconsistent supervision documentation, missing 30-minute check entries, and falls that occurred while the chart showed 1:1 or frequent checks. The resident sustained multiple injuries, including a broken nose and later a patella fracture, while staff and records were unclear about when 1:1, 15-minute, or 30-minute monitoring was actually in place. A second resident with severely impaired cognition was left in bed attached to a Hoyer lift without staff present, and staff interviews confirmed the resident was unsupervised during the transfer setup.
A resident with a history of lumbar compression fracture, repeated falls, and a care plan for 2-person assist transfers sustained a severe leg laceration when a CNA assisted him alone from a recliner to a wheelchair after he refused to wait for another staff member. The resident’s foot caught behind the wheelchair wheel, the wound required 10 stitches, and the facility’s investigation confirmed the CNA did not follow the 2-assist transfer plan.
Damaged flooring was observed in multiple common areas, including the east hall leading to therapy, the southeast hall, and the dining room near the vending machines. Surveyors found cracked, missing, and buckling tiles, and staff said the flooring had been deteriorating for a long time. Residents who independently ambulated or used assistive devices used these areas, including residents who traveled to therapy, moved on the southeast hall, and accessed the vending machines.
A facility failed to maintain an effective process for labeling resident clothing and did not ensure missing laundry was returned or replaced for three residents. Laundry staff reported frequent unmarked items, daily missing-item complaints, and multiple unclaimed clothing piles, while one resident’s POAHC replaced missing pants and shirts, another resident’s missing nightgown was not found, and a third resident reported missing underwear and t-shirts and receiving other residents’ items.
Care plan not followed for pressure relieving boots. A resident with severe cognitive impairment, dementia, Wernicke's encephalopathy, and Hospice services had an order and care plan intervention for pressure relieving boots to both feet at all times. The surveyor observed the resident in bed without the boots, and an RN verified the boots were off before applying them. A UM confirmed the resident should have had the boots on at all times.
Failure to provide ordered oxygen therapy and care plan guidance for a resident with severe cognitive impairment, hospice services, and diagnoses including alcohol-induced dementia and Wernicke's encephalopathy. The resident had an order for 2 L O2 while resting in bed to prevent hypoxia and maintain O2 saturation above 90%, but was observed in bed without oxygen. RN verified the resident was not receiving O2, and the care plan did not include oxygen goals or interventions.
Inadequate supervision during falls and mechanical lift transfer
Penalty
Summary
The facility did not ensure adequate supervision and fall-prevention interventions for a resident with severe cognitive impairment, impulsive behavior, and a long history of recurrent falls. The resident had diagnoses including Alzheimer’s disease with early onset dementia, repeated falls, anxiety disorder, a nasal bone fracture, and a right patella fracture. The resident’s MDS showed a BIMS score of 5 out of 15, and the record reflected multiple fall-risk interventions, including 1:1 supervision, 15-minute checks, and 30-minute checks at different times during the stay. The resident sustained numerous unwitnessed falls while the documentation for supervision was inconsistent and incomplete. The record showed gaps and missing days on 30-minute check sheets, and the medical record did not consistently identify when the resident was on 1:1 supervision, 15-minute checks, or 30-minute checks. Several falls occurred when the resident was documented as being on 30-minute checks, but the check sheets were blank or did not show the resident had been seen within the prior 30 minutes. The resident also fell while care planned for 1:1 supervision, including an event where the resident was found on the floor after staff heard a loud bang and the chart indicated the resident had last been seen in bed about 45 minutes earlier. The resident’s record also showed that supervision changes were not clearly reflected in the care plan, and staff interviews confirmed confusion about when the resident was on 30-minute checks versus 1:1 supervision. The resident continued to fall despite multiple interventions, including staff education and repeated fall reviews. The resident was later sent to the hospital after additional falls, and an x-ray revealed a right patella fracture. The resident’s spouse and family expressed concern that the resident’s care needs were not adequately met because of the numerous falls. A second resident with severely impaired cognition was left in bed attached to a Hoyer lift without staff in the room. This resident had diagnoses including alcohol-induced dementia and Wernicke’s encephalopathy, and the care plan directed transfer with the assistance of 2 staff using a full-body mechanical lift and sling. A hospice social worker observed the resident moaning and groaning in bed in the sling with no staff present, and it took 10 to 15 minutes to locate staff. Staff interviews confirmed that the resident had been left unsupervised while attached to the lift, even though the resident was not well-oriented and the facility’s practice was to use two staff for Hoyer transfers.
Failure to Follow 2-Person Transfer Assistance Plan
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were used to prevent accidents for a resident who was care planned for a 2-person assist with transfers. The resident had a history that included a wedge compression fracture of the lumbar spine, restless leg syndrome, congestive heart failure, edema, cognitive communication deficit, difficulty walking, need for assistance with personal care, and repeated falls. The resident’s care plan documented extensive assistance with transfers and use of a wheeled walker. During an evening transfer from a recliner in the spouse’s room to a wheelchair, the resident was trying to get up and wanted to return to his room. A CNA responded to the call light and told the resident she needed to get a second staff member because the resident required 2-person assistance. The resident said he would not wait and would transfer himself. The CNA then decided to assist the resident alone rather than leave the room to obtain another staff member. While assisting the resident to the wheelchair, the resident’s foot became caught behind the small wheel in the back of the foot pedal. The resident sustained a laceration to the left lower leg with muscle and fatty tissue exposed, required 10 stitches, and was sent to the ER for evaluation and treatment. The facility’s investigation and staff statements confirmed that the resident was care planned for 2-person assist transfers and that the CNA transferred him without the required second staff member. The DON also stated that the CNA did not follow the resident’s care plan for 2-assist transfers and transferred the resident by herself, resulting in the laceration.
Damaged Flooring in Hallways and Dining Area
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for residents who independently used the east hall to access therapy services, the southeast hall, and the dining room area near the vending machines. Surveyors observed cracked, missing, and lifting floor tiles on the east hall across from the conference room, with 23 square tiles that were cracked, missing pieces, buckling, and moving when stepped on. The therapy room was located at the end of that hall, and the surveyor noted that the flooring had been pulling up with missing pieces for about 1 to 2 years, according to housekeeping staff. The maintenance director stated the flooring was not in the building budget to be replaced and that the facility did not have the same size tiles available. Surveyors also observed a missing tile on the southeast wing by the shower room door with residual glue remaining on the floor, and buckling flooring in the dining room near the soda and candy vending machines, including a missing tile approximately 4 inches by 4 inches and four tile strips about 3 feet long that moved when stepped on. The soda machine had a note stating it was out of service, and a wheeled cart was placed beside it covering additional buckling tiles. Staff interviews identified residents who independently ambulated in these areas, including residents who could travel to therapy without staff assistance, residents who could move independently on the southeast hall, and residents who could independently use the dining room vending machines.
Missing Resident Clothing Not Located or Replaced
Penalty
Summary
The facility did not have an effective process for labeling resident clothing and did not ensure missing laundry was returned or replaced for three residents. The grievance policy stated that missing clothing issues were to be forwarded to the Laundry Supervisor, but no resident-belongings policy was provided. Laundry staff reported that many unmarked items came through the laundry, that residents reported missing items daily, and that the current labels did not always stay on. Surveyors observed multiple notes about missing items posted on the laundry room wall, along with racks, boxes, and a hanging rack of unclaimed or unlabeled clothing. One resident’s POAHC reported that pants and shirts were missing after admission, and the POAHC replaced the items when the facility could not locate them, with no follow-up communication from the facility. Another resident told laundry staff that a nightgown was missing, but it had not been found or replaced. A third resident reported missing underwear and t-shirts, stated they had received other residents’ items and returned them, and said their supply had decreased from six pairs of underwear to three. Interviews with CNA, SW, and NHA staff showed inconsistent understanding of who labeled clothing, with some stating housekeeping, nursing, laundry, or families handled labeling, and the NHA was not aware of the missing-item concerns.
Care Plan Not Followed for Pressure Relieving Boots
Penalty
Summary
The facility did not ensure the care plan was followed for R3, who had an order and care plan intervention for pressure relieving boots to bilateral feet at all times. R3 was admitted to the facility, received Hospice services, and had diagnoses including alcohol induced dementia and Wernicke's encephalopathy. The MDS dated 5/13/26 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The medical record and care plan included an intervention dated 12/20/25 for pressure relieving boots to bilateral feet at all times every shift. On 7/27/26 at 9:48 AM, the surveyor observed R3 in bed without the pressure relieving boots, despite a sign in the room stating the boots should be on at all times when in bed. At 10:13 AM, RN-C verified R3 did not have the boots on and applied them. On 7/28/26 at 9:37 AM, UM-D confirmed R3 should have pressure relieving boots on at all times.
Failure to Provide Ordered Oxygen Therapy and Care Plan Guidance
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident, R3, who had an order for oxygen to prevent low oxygen saturation levels. R3 was admitted to the facility, received Hospice services, and had diagnoses including alcohol-induced dementia and Wernicke's encephalopathy. A MDS assessment dated 5/13/26 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The medical record included an order for 2 liters of oxygen while resting in bed two times daily for hypoxia and to maintain O2 saturation above 90%, dated 7/6/26. However, R3's care plan did not include goals or interventions for oxygen use. On 7/27/26 at 9:48 AM, the surveyor observed R3 in bed without oxygen. During interview, RN-C verified R3 was not receiving oxygen and stated they would check the care plan to see if oxygen was required; RN-C then reviewed the orders and confirmed oxygen should be used when in bed at 2 liters via nasal cannula. On 7/28/26, UM-D stated R3 should wear oxygen anytime they were in bed for a nap and that the care plan should also reflect oxygen use.
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Compliance trends in Wisconsin
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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).
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