Based on interview and medical record review, the facility did not revise care plans, to accurately reflect the comprehensive needs for 1 of 9 residents, out of a total sample of 11 (R1). This had the potential to affect the 72 female residents in the facility, out of a total of 105 residents. R1 is a registered sex offender. On 2/5/18 R1 was observed with his penis out trying to lure R2 to him and sometime in (MONTH) (YEAR) R1 asked confused female resident R4 if she wanted to have sex with him, asking if R4 would like to touch him or if he could touch R4. R1's care plan was not updated to monitor inappropriate sexual behaviors, actions or comments until 3/7/18 but this plan was not specific and its approaches were not placed on the CNA (certified nursing assistant) care plan. …
F657 citations in Wisconsin
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F657 less often than its own record predicts
0.74 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F657 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 the comprehensive care plan was reviewed by the interdisciplinary team and resident/resident representative after each assessment, including both the comprehensive and quarterly review assessments for 6 of 16 sampled residents (R2, R3, R35, R28, R7, & R41), reviewed for care conferences. R2 did not have quarterly care conference meetings. R3 did not have quarterly care conference meetings. R35 did not have quarterly care conference meetings. R28 did not have quarterly care conference meetings. R7 did not have quarterly care conference meetings. R41 did not have quarterly care conference meetings. Evidenced by: The facility policy entitled, Comprehensive Care Plans, dated 2/2026, states, in part: . …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 1.45% | 0.68× |
| 2024 | 1.19% | 0.62× |
| 2025 | 1.38% | 0.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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