Based on record review and interview, the facility did not ensure 1 (R165) of 1 residents reviewed for baseline care plans included healthcare information and instructions necessary to provide effective person-centered care and to properly care for R165. R165 was admitted into the facility for short term respite care on 6/30/21. Preadmission paperwork provided to the facility includes a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Preadmission paperwork from R165's health care provider documents problems with strictures of esophagus. …
F655 citations in Wisconsin
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F655 less often than its own record predicts
0.39 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F655 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 a baseline care plan was developed and implemented within 48 hours of a resident's admission for 3 (R10, R98, and R35) of 4 residents. *R10's baseline care plan for post-traumatic stress disorder was not completed within the required 48-hour timeframe. *R98's baseline care plan for risk for pressure injury/skin integrity was not thoroughly completed within the required 48-hour time frame. *R35's baseline care plan for anticoagulant, antidepressant, diuretic, and antipsychotic was not completed within the required 48 hours timeframe. …
Based on Resident (R) interview, staff interview, and record review, the facility did not ensure a baseline care plan summary was provided to 1 (R168) of 1 sampled new admission residents. The facility did not provide or offer to provide a copy of R168's baseline care plan or a summary thereof to R168. Findings include: On 10/28/19 at 10:04 AM, Surveyor interviewed R168 who indicated a copy of the baseline care plan was not offered to R168. R168 expressed interest in having a copy of R168's own care plan. On 10/28/19, Surveyor reviewed R168's medical record which documented R168 was admitted to the facility on [DATE]. On 10/29/19 at 3:46 PM, Surveyor interviewed Social Worker (SW)-F. SW-F verified being primarily responsible for care conferences. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.61% | 0.77× |
| 2024 | 0.35% | 0.51× |
| 2025 | 0.26% | 0.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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