Based on interview and record review, the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 (R414) of 1 resident. The facility did not consistently update the physician or the power of attorney (POA) with changes in R414's condition; in failing to do so, the facility did not ensure collaboration of care between hospice, the facility, the physician, and the power of attorney. R414 had a change in condition with an unwitnessed fall on 10/27/23. …
F849 citations in Wisconsin
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wisconsin cites F849 more often than its own record predicts
2.15 times the share F849 takes of citations nationally.
Of every deficiency written in Wisconsin in 2025, this is the portion that was F849.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wisconsin surveyors wrote
F849 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 record review and interviews, the facility did not ensure 1 (R2) of 1 resident's reviewed receiving hospice services had effective coordination of care between the facility and hospice services to ensure care was provided as indicated. *R2 was admitted to hospice services on 7/21/2022. R2's hospice care plan and facility care plan were not similar resulting in lack or coordination between hospice and the facility. Hospice was not part of R2's care conferences to coordinate care for R2, and hospice staff did not communicate with facility staff upon exiting the building on 12/16/2022 to allow the facility to intervene when R2 was refusing to have their bed lowered resulting in R2 having an unwitnessed fall out of bed that resulted in a major injury. …
Based on interview and record review the facility did not ensure communication between the facility and hospice for 2 (R27 & 29) of 3 residents reviewed for hospice.R27 & R29 receives hospice services from the same hospice agency. The facility did not have communication sheets from hospice staff providing services, such as Certified Nursing Assistants, Social Worker, etc. for R27 & R29. Hospice RN progress reports are not consistently sent to the facility for R27 & R29. The hospice agency did not provide the facility with hospice MD (medical doctor) recertification of terminal illness for R27 & R29. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.33% | 1.06× |
| 2024 | 0.42% | 1.37× |
| 2025 | 0.58% | 2.15× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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