Based on observation, interview, and record review the facility did not ensure that 1 (R8) of 5 residents drug regimen was free from unnecessary drugs. R8 was prescribed Risperidone for verbal and physical aggression. The facility failed to adequately monitor R8's response to Risperidone and failed to recognize adverse consequences of Risperidone therapy including lethargy, decreased Activities of Daily Living (ADL) function and decreased oral intake. The facility failed to adjust R8's Risperidone when R8 presented with adverse consequences. R8 was administered Risperidone (Antipsychotic) daily starting on 6/22/25 following two days of intermittent verbal and physical aggression. …
F605 citations in Wisconsin
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F605 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F605 findings written in Wisconsin, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs for 1 of 5 residents reviewed for unnecessary medications (R2) out of a sample of 16 residents.-The facility nurse transcribed R2's order as Diazepam 2mg tablet. Take 0.5 tablet twice a day, instead of take 0.5mg tablet twice a day as needed (PRN). R2 received a total of 9 doses of Diazepam.Findings include:The facility policy with a subject titled, Transcription of Physician Orders, last revised 06/2018, includes: Nurse will initiate a transcription check list for all new orders. Nurse taking order will follow and complete areas on the transcription check list.Nurse will make a copy of the order and staple to the transcription check list. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2024 | 0.04% | 1.70× |
| 2025 | 0.66% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction