Based on interview and record review, the facility failed to appropriately pre-screen a resident before admission to determine whether the facility could meet the resident's needs and subsequently discharged the resident, because they were unable to provide the required care for one resident (Resident (R1) of one resident reviewed for the Facility Assessment. This failure had the potential to result in undue hardship for residents and disrupt the continuity of care. Findings include: Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/24/26, located in the electronic medical record (EMR) under the MDS tab, revealed an admission date of 02/24/26 and diagnoses including cerebral infarction due to thrombosis of precerebral arteries, hemiplegia… …
F838 citations in Wisconsin
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F838 less often than its own record predicts
0.72 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F838 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 staff interview and record review, the facility did not ensure the Facility Assessment which documented the types of care required by the facility resident population and the Emergency Preparedness Plan were reviewed at least annually, as required. This had the potential to affect all residents that resided at the facility. The facility had not updated the Facility Assessment since 4/8/2020. The facility had not updated the Emergency Preparedness Plan since July 2021. Findings include: On 9/26/22 at approximately 1:50 PM, the Surveyor reviewed the Facility Assessment and the facility Emergency Preparedness Plan. The Facility Assessment was last updated on 4/8/2020 and the Emergency Preparedness Plan was last updated July 2021. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.22% | 1.32× |
| 2024 | 0.17% | 0.90× |
| 2025 | 0.18% | 0.72× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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