Based on record review, observations, and staff interviews, the governing body did not implement policies regarding the management and operation of the facility to ensure residents received care that attained or maintained their highest practicable level of physical, mental, and psychosocial well-being this had the potential to affect all 71 residents. This resulted in 9 Immediate Jeopardy citations being issued at Nutrition/Hydration (F692), Sufficient Nurse Staffing (F725), Qualified Dietary Staff (F801), Sufficient Dietary Staff (F802), Menus Being Followed (F803), Transfer and Discharge Requirements (F622), Permitting Residents to Return to the Facility (F626), Provisions of Medically Appropriate Social Services (F745), and Governing Body (F837). …
F837 citations in Wisconsin
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F837 less often than its own record predicts
0.67 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F837 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 upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing and implementing policies and procedures regarding the operations of the facility. The facility's governing body did not ensure that proper resources were allocated to ensure that the HVAC (Heating, Ventilation, and Air Conditioning) system providing heat to the entire facility was maintained in a functioning manner. This created the likelihood where services necessary to maintain operations of the facility along with the care and treatment of all residents may be impacted by the failures of the governing body. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2024 | 0.35% | 3.84× |
| 2025 | 0.04% | 0.67× |
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