Based on interview and record review, the facility did not complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R54) of 3 residents reviewed for hospice.R54 enrolled in hospice services on 3/19/26. The facility did not complete a Significant Change MDS until 5/15/26.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual version 1.19.1 dated 10/2024 documents:A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program . …
F637 citations in Wisconsin
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F637 less often than its own record predicts
0.30 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F637 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.
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.33% | 1.09× |
| 2024 | 0.17% | 0.78× |
| 2025 | 0.07% | 0.30× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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