Based on interview and record review, the facility did not ensure a resident (R) received a written notice of the reason for transfer to the hospital or a written notice for a bed hold for 1 (R24) of 4 residents reviewed out of 17 sampled residents.-R24 did not receive a written notice of transfer to the hospital or a bed hold notification on 07/07/26.Findings include:R24 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes with neuropathy.On 7/27/26, R24 was admitted to the hospital following an episode of acute respiratory failure and an exacerbation of heart failure. R24's most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13/15, which means R24 has intact cognition. …
F628 citations in Wisconsin
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F628 more often than its own record predicts
1.52 times the share F628 takes of citations nationally.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F628 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 that proper notification was sent to the State Long-Term Care Ombudsman for 6 (R1, R2, R3, R8, R10 and R103) of 6 residents reviewed for transfers or discharges. *R1 was transferred to the hospital on 8/5/25 and 10/23/25. The facility did not notify the State Ombudsman of R1's hospitalizations. *R2 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R2's hospitalization. *R3 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R3's hospitalization. *R8 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R8's hospitalization. *R10 was transferred to the hospital on [DATE] and 2/3/26. …
What else Wisconsin surveyors cite →
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