Based on interview and record review, the facility failed to ensure 4 (R21, R66, R109, and R7) of 19 sampled residents received treatment and care based upon a comprehensive assessment and a comprehensive person centered plan of care and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act.) *R21 returned from an appointment outside of the facility on 10/27/25 with a large hematoma on the front of R21's left shin. R21's leg wound opened and needed to be debrided on 11/19/25. On 11/26/25, R21's left leg wound became infected. Facility staff did not follow Wound Nurse Practitioner (NP)-F's treatment orders. …
F684 citations in Wisconsin
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F684 more often than its own record predicts
1.01 times the share F684 takes of citations nationally.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F684 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 each resident received the necessary care and services in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act) to meet each resident's physical needs for 1 of 3 sampled residents (R1). R1 experienced a change in condition with no bowel movements for five (5) days which lead to a distended abdomen, nausea and vomiting, severe constipation, ileus (a condition where the intestine slows down or stops pushing food and waste through the body) requiring a nasogastric tube (a tube passed through the nose and into the stomach for decompression) and aggressive bowel regimen. …
Based on interview, and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 3 Residents (R12) reviewed out of total sample to 15 residents. R12 sustained a fall, R12 was not assessed by an RN (Registered Nurse) and neuro checks were not completed following the fall. Evidenced by:According to N6, Wisconsin Nurse Practice Act, An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 3.95% | 1.09× |
| 2024 | 4.30% | 1.08× |
| 2025 | 4.34% | 1.01× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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