Based on observation, record review, and interview, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and behavioral health related services to assure resident safety for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents reviewed (R55). R11 had expressed suicidal ideations related to his chronic pain (phantom limb pain) multiple times in the two months preceding R11 stabbing himself in the chest with scissors due to unrelieved pain. R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. …
F741 citations in Wisconsin
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F741 more often than its own record predicts
1.52 times the share F741 takes of citations nationally.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F741.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F741 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, and record review, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and related services to assure resident safety and for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident's (R) reviewed (R253) who have a mental health diagnosis as well as a history of self-harm statements. R253 verbalized suicidal ideation which was not recognized by the facility and was not taken seriously. …
What else Wisconsin surveyors cite →
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