Based on observation, interview, and record review, the facility did not ensure unlicensed staff would not administer medications to 1 resident (R27) for 5 residents reviewed for medication administration in a sample of 23 residents.Certified Nursing Assistant (CNA) D was observed by Surveyor applying a Lidocaine external patch 4% to R27's back.Findings include:The facility policy titled Administering Medication, revised 01/22/2024, states, Only licensed staff.may administer or record the administration of medications.certified medication technicians may administer specific medications under the direction of a licensed nurse if competency has been determined.R27 was admitted to the facility on [DATE] and has diagnoses of cerebral palsy and back pain. …
F659 citations in Wisconsin
Resident Assessment and Care Planning Deficiencies
Provide care by qualified persons according to each resident's written plan of care.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F659 more often than its own record predicts
3.76 times the share F659 takes of citations nationally.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F659 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 | 0.06% | 1.46× |
| 2024 | 0.10% | 3.55× |
| 2025 | 0.15% | 3.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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