Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) reviewed. (R33) R33 was not given enteral feeding nutrition as ordered; instead R33 received twice as much as ordered resulting in vomiting and aspiration, requiring suctioning and transfer to hospital on [DATE] where R33 expired on [DATE]. The facility's failure to properly monitor, assess, and correctly follow physician (MD) orders and treatments for enteral feeding resulted in resident receiving twice as much enteral feeding as ordered and created a finding of Immediate Jeopardy (IJ) that began on [DATE]. …
F693 citations in Wisconsin
Tube feeding · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F693 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F693.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F693 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 observation, interview, record review, and policy review, the facility failed to ensure one out of two sampled residents (Resident (R)185) reviewed for tube feeding was provided with tube feeding administration in accordance with physician's orders. The facility failed to administer the prescribed formula and failed to ensure medication (pills) were crushed. R185 was hospitalized on [DATE] with a clogged feeding tube. The facility staff administered R185 medications in a pill form that were not sufficiently crushed which clogged the feeding tube. …
Based on interview and record review, the facility failed to obtain doctor's orders for the size of the PEG tube and mls to fill the balloon or complete a care plan with interventions for nursing staff to follow for 1 of 2 residents (R5) reviewed with a feeding tube out of a sample of 28 residents. Findings:R5 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 13 which indicated R5 was cognitively intact. R5 had diagnosis of gastrostomy. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.50% | 0.67× |
| 2024 | 0.84% | 1.19× |
| 2025 | 0.66% | 0.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction