Based on interview and record review, the facility did not ensure 1 of 12 nurses reviewed had the proper licensure in accordance with Wisconsin state law licensing requirements. This had the potential to affect all 47 residents in the facility. This is evidenced by: On [DATE], Surveyor requested and received licensure information for 12 nurses at the facility. Upon reviewing nursing licensures, Surveyor reviewed documentation for Licensed Practical Nurse (LPN) N. The facility did not have documentation of a Wisconsin license for LPN N. The facility did provide documentation for ACT 10 (temporary licensure), which stated LPN N started employment at the facility on [DATE]. The form was not signed by the Director of Nursing (DON) B until [DATE]. ACT 10 expired [DATE]. …
F839 citations in Wisconsin
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Wisconsin cites F839 less often than its own record predicts
0.62 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin in 2024, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F839 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.
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 2.82× |
| 2024 | 0.04% | 0.62× |
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