Based on staff interview and record review, the facility did not have a licensed nurse on duty to meet the needs of residents for approximately 2.5 hours on the [DATE] PM shift. This had the potential to affect 23 of 23 residents (R) residing in the facility. On [DATE], an agency nurse who worked the AM shift left the facility without licensed nurse coverage for the PM shift. The facility was without a nurse for approximately 2.5 hours. Due to not having a licensed nurse on duty, 3 residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R8, R9, R10, R11, R12, R5, R1, R13, R14, R15, R16, R7, R3, and R17) did not receive medication in accordance with physician orders. …
F725 citations in Wisconsin
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F725 less often than its own record predicts
0.75 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F725 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, record review, and staff and resident interviews, the facility did not ensure they had sufficient nursing staff to provide nursing care and services to all the residents and assure resident safety as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This has the potential to affect all 54 residents residing in the facility. Example#1: The facility did not ensure 8 of 14 residents (R2, R18, R21, R34, R15, R10, R3, R48) received prompt response to their needs and call lights due to insufficient staffing as voiced during individual resident interviews and resident group meeting. …
Based on interview and record review, the facility did not ensure sufficient nursing staff was provided to all residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Surveyor conducted a record review of the facility's nursing staff schedule and verified the facility is not providing staffing levels that meet the facility's identified staffing needs documented in the facility assessment for the night shift. The facility did not consistently designate a licensed nurse to serve as a charge nurse on each tour of duty. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.33% | 0.41× |
| 2024 | 0.84% | 1.05× |
| 2025 | 0.58% | 0.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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