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
Failure to Supervise Resident at Risk for Elopement: A resident with severe cognitive impairment and known exit-seeking behavior was not accurately assessed or care planned for elopement risk. Staff observed the resident in another resident’s room, then an exit alarm sounded; an LPN closed the door and reset the alarm without checking outside, and staff later could not locate the resident. The resident was found outside the secured unit in cold weather with injuries and confusion, while video showed the resident leaving the building and staff not stepping outside to verify whether anyone had eloped.
Failure to Follow Transfer Plan During Shower Care Resulted in Resident Hip Fracture A resident with dementia, impaired mobility, and a history of falls required a 1-person assist with a 2WW for transfers. During shower care, a CNA transferred the resident without a gait belt or walker, and the resident was lowered to the floor. When staff later tried to stand the resident, the resident had severe R hip pain, a shortened and externally rotated leg, and was sent to the hospital with an intertrochanteric femur fracture.
Food was not maintained in a safe and sanitary manner. A scoop was left in a flour bin, bacon and pie crusts were uncovered and unlabeled in the walk-in refrigerator, a staff member with facial hair was not wearing a beard restraint, and food brought in by a family member was found unlabeled and undated in a hallway refrigerator. The DM acknowledged the issues and stated the items should have been covered, labeled, dated, and properly restrained.
Missing QAPI Training for CNAs: Mandatory yearly QAPI in-service training was not documented for 5 sampled CNAs. The facility assessment listed several yearly staff training topics and competencies, but QAPI was not included in the training plan. The NHA confirmed CNAs are required to complete yearly in-service hours and stated CNA training should include QAPI, though the facility does not provide training directly titled QAPI.
Five of five sampled CNAs did not have documented yearly compliance and ethics in-service training. The facility assessment states staff are to receive training upon hire and on a yearly basis, and the NHA confirmed that CNA annual in-service education should include compliance and ethics after reviewing the nurse aide in-service records.
Five of five sampled CNAs did not have documented annual in-service education totaling 12 hours, and their records did not include dementia management or abuse prevention training. The facility assessment listed abuse and caring for persons with dementia among required training topics, and the NHA agreed the CNA in-service records did not meet the yearly hour requirement and should include dementia and abuse education.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for a resident with dementia and a known pattern of exit seeking. The resident had diagnoses including unspecified dementia, Alzheimer’s disease, Major Depressive Disorder, COPD, and insomnia, and her MDS showed severely impaired cognition with a BIMS score of 3 out of 15. Her comprehensive care plan noted periodic exit seeking, but it did not contain interventions or goals related to that behavior. The resident’s elopement risk assessment was also incomplete and inaccurate, with missing answers and no score, and facility leadership acknowledged that the assessment should have been accurate and complete. On the evening of the incident, staff observed the resident in another resident’s room, and later an emergency exit alarm sounded. An LPN reported that she looked at the door, saw it open, did not see footprints or snow disturbance, closed the door, and turned off the alarm. The LPN and a CNA then searched inside the building but could not find the resident. The CNA later stated she initialed the 15-minute check sheet without actually checking on the resident because she was told the resident had been seen by the LPN. The 15-minute check sheet showed observations continuing until 8:45 PM even though staff reported they were unable to locate the resident. The resident was later found outside the facility after exiting the secured memory care wing. Facility records, police documentation, EMS, and the ER report described that she had wandered into cold weather, was confused and disoriented, had abrasions and injuries, and had a low body temperature. Video footage showed the resident leaving the building at 8:27:56 PM, walking across the parking lot, and continuing onto the street while staff did not step outside to check the area. The facility’s misconduct report stated that two agency staff on the wing did not respond for over two minutes when the emergency exit alarm sounded and did not look outside to ensure no residents had eloped.
Failure to Follow Transfer Plan During Shower Care Resulted in Resident Hip Fracture
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision and assistive devices were used to prevent accidents for a resident who required a 1-person assist with a 2-wheeled walker for transfers. The resident had diagnoses including dementia, osteoarthritis of the knee, difficulty walking, history of falling, and later documented intertrochanteric fracture of the right femur. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 9/15 and documented the need for staff assistance with transfers. The care plan directed assist of 1 with a 2WW for ambulation/locomotion, and the resident’s fall risk assessments showed medium to high fall risk. During a morning transfer in the tub room, a CNA transferred the resident from the shower chair without using a gait belt and without the walker. The resident was lowered to the floor and initially had no obvious injury, but when staff later attempted to stand the resident to pull up pants, the resident could not bear weight and complained of severe right hip pain. The resident’s right leg was noted to be shortened and externally rotated. The resident was then transferred by Hoyer lift, EMS was called, and the resident was taken to the hospital. The emergency department documented right hip pain after the resident was assisted in the shower and found a comminuted moderately displaced versus impacted right proximal femur intertrochanteric fracture. Surveyor observation later showed staff using the resident’s care plan and transferring the resident with a Hoyer lift and two staff. Interviews with nursing staff and the DON confirmed that the resident had not been transferred according to the care plan during the incident, and that the gait belt and walker were not used when the resident was moved from the shower chair and when staff attempted to stand the resident afterward.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. During an initial kitchen walkthrough on 6/29/26, the surveyor observed a scoop left in the flour bin and observed bacon and pie crusts uncovered in the walk-in refrigerator with no label or date. The Dietary Manager acknowledged that the scoop should not have been left in the bin and stated that food items should be covered, labeled, and dated. On 6/30/26, the surveyor observed a staff member with facial hair not wearing a beard restraint. Later that day, the surveyor observed items in the 100-hallway refrigerator that were not labeled and dated and were identified by the Dietary Manager as fruit brought in by a family member. The Dietary Manager stated these items should have been labeled and dated and indicated staff with facial hair should wear a beard restraint. On 7/2/26, the Nursing Home Administrator indicated understanding of these concerns.
Missing QAPI Training for CNAs
Penalty
Summary
Mandatory yearly QAPI in-service training was not included for 5 of 5 randomly sampled CNAs: CNA J, CNA K, CNA L, CNA M, and CNA N. The facility assessment, last reviewed 1/2026, stated that staff would receive training and education upon hire, yearly, and as needed, and listed topics such as communication, resident rights, abuse, infection control, and culture change, along with competencies including person-centered care, ADLs, disaster, infection control, and caring for persons with Alzheimer's or another dementia. Surveyor review noted that QAPI training was not included in the facility's training plan. During interview on 7/02/26, the NHA stated that CNAs are required to complete 12 hours of yearly in-service/education and confirmed that CNA yearly training should include QAPI. The NHA also stated the facility does not provide training directly titled QAPI, but instead presents interventions and actions put in place for issues identified. Review of the Nurse Aide In-Service Records for CNA J, CNA K, CNA L, CNA M, and CNA N showed they did not receive documented mandatory yearly QAPI in-service training.
Missing Annual Compliance and Ethics Training for CNAs
Penalty
Summary
The facility did not include an effective way to communicate the standards, policies, and procedures of its compliance and ethics program through a training program for 5 of 5 CNAs randomly sampled. CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented yearly compliance and ethics in-service training. The Facility Assessment, last reviewed 1/2026, states that staff will be provided training and education upon hire, routinely on a yearly basis, and as needed, and lists training topics including communication, resident rights, abuse, infection control, and culture change. During an interview on 7/02/26 at 1:00 PM, the NHA reviewed the Nurse Aide In-Service Records for the five CNAs and confirmed that yearly CNA in-service/education should include compliance and ethics.
CNA Annual Training Records Lacked Required Hours and Dementia/Abuse Content
Penalty
Summary
Nurse aide continuing competence was not ensured because 5 of 5 randomly sampled CNAs—CNA J, CNA K, CNA L, CNA M, and CNA N—did not have documented yearly in-service education totaling at least 12 hours, and their records did not include dementia management training or resident abuse prevention training. The facility assessment, last reviewed in 1/2026, stated that staff training and education would be provided upon hire, routinely on a yearly basis, and as needed, and it listed abuse and caring for persons with Alzheimer's or another dementia among the training and competency topics. During interview on 7/02/26, the NHA stated that CNAs are required to receive 12 hours of yearly in-service education and agreed that the reviewed Nurse Aide In-Service Record sheets for the five CNAs did not meet that requirement; the NHA also indicated that yearly in-service education should include dementia and abuse training.
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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).
Trusted data from CMS and state health departments
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