Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plum City Care Ctr during CMS and state inspections, most recent first.
The facility failed to adhere to professional standards for food service safety by not labeling opened dry goods with an open date, as observed in the dry storage area. Bags of noodles were found opened without dates, contrary to the facility's policy, potentially affecting all 37 residents. The Dietary Manager acknowledged the oversight and discarded the noodles due to safety concerns.
The facility failed to provide adequate pressure ulcer care and prevention for residents at risk. One resident was left in a Broda chair for over five hours without repositioning, leading to redness on the buttocks. Another resident with multiple pressure injuries was not repositioned to offload pressure as ordered. A third resident did not have the prescribed prevalon boot applied, and a fourth resident was not repositioned or provided with the ordered cushion, resulting in skin redness. These failures indicate a lack of adherence to care plans and physician orders.
A resident with COPD and chronic respiratory failure was observed self-administering nebulizer treatments without the required pre and post respiratory assessments by nursing staff. The resident managed their own treatments, and staff left medication at the bedside. The RN did not perform necessary assessments, and documentation was inconsistent, indicating a deficiency in respiratory care.
The facility failed to properly dispose of discontinued medications and allowed a resident to self-administer nebulizer treatments without an assessment. Expired Lorazepam bottles were found in storage, and a resident was observed managing their own nebulizer and inhalers without proper authorization. The DON acknowledged the oversight in medication disposal, and the RN admitted to leaving medications at the bedside, contrary to physician orders.
A resident with COPD and other conditions was found managing their own Ventolin inhalers, which were left unattended in their room, contrary to facility policy requiring medications to be stored in locked compartments and administered under supervision. The DON confirmed that the resident should not have been using inhalers freely without staff oversight.
A CNA failed to perform hand hygiene before donning gloves while providing peri care to a resident. The CNA was observed handling the resident's clothing and bedding with contaminated gloves, contrary to the facility's policy and WHO guidelines. The DON confirmed the expectation for hand hygiene after resident contact.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation of the dry storage area, it was noted that some food products, specifically bags of noodles, were opened without being labeled with an open date. This practice is contrary to the facility's policy, which requires that opened dry goods be labeled with an open date to ensure food safety. The absence of open dates on these products means that staff could not determine how long the food had been stored, potentially compromising food safety for all 37 residents in the facility. The Dietary Manager (DM) was interviewed and acknowledged that staff are expected to label opened food items with an open date to track their usability. The DM expressed discomfort with serving the noodles that lacked open dates and decided to discard them due to the uncertainty of their safety. The facility's policy, revised in November 2024, mandates adherence to a dry food storage timeline and the FIFO principle, which were not followed in this instance. This oversight in food storage practices highlights a lapse in the facility's adherence to its own food safety protocols.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for four residents at moderate to high risk of pressure injury development. One resident, who was totally dependent on staff for daily tasks and had a moderate risk score on the Braden Scale, was observed sitting in a Broda chair for over five hours without repositioning or offloading, contrary to the care plan that required repositioning every 2-3 hours. The resident's buttocks were noted to be reddened after being transferred to bed, indicating potential skin breakdown due to prolonged pressure. Another resident, admitted with multiple pressure injuries and on hospice care, was not repositioned adequately to offload pressure from the coccyx and hip as ordered. Despite being at high risk and having a stage 3 pressure injury, the resident was observed lying in bed with the lower back and coccyx flat against the mattress for extended periods, without repositioning by staff. The facility's failure to adhere to the care plan and physician orders for repositioning every two hours contributed to the lack of pressure relief. Additionally, a resident with a history of an unstageable pressure injury to the right heel did not have the prescribed prevalon boot applied while in bed, as observed on multiple occasions. The staff failed to follow the care plan and physician orders to apply the boot and elevate the feet, which are critical interventions for pressure injury prevention. Another resident, dependent on staff for all care, was observed sitting in a Broda chair without the ordered pommel wedge cushion and was not repositioned for several hours, leading to redness and creases on the skin, indicating potential pressure injury development.
Inadequate Respiratory Care for Resident Self-Administering Nebulizer
Penalty
Summary
The facility failed to ensure appropriate respiratory care for a resident with chronic respiratory conditions, including COPD and chronic respiratory failure with hypoxia. The resident, who had intact cognition, was observed self-administering nebulizer treatments without the required pre and post respiratory assessments by nursing staff. The resident indicated that they managed their own nebulizer treatments, and staff would leave the medication at the bedside if the resident was not ready to take it. During observations, the surveyor noted that the registered nurse did not perform pre-treatment assessments, such as auscultating the lungs, nor did they conduct post-treatment assessments to confirm the completion and effectiveness of the nebulizer treatment. The Director of Nursing confirmed that the expectation was for nursing staff to perform respiratory assessments both before and after nebulizer treatments, even if the resident was self-administering. However, documentation of these assessments was inconsistent or absent in the nurse progress notes. The lack of adherence to the facility's protocol for respiratory care and the absence of documented assessments highlight a deficiency in the care provided to the resident, potentially impacting the resident's respiratory health management.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure the proper disposal of discontinued medications and the accurate administration of medications to residents. During a survey, it was observed that expired medications were present in one of the medication storage areas. Specifically, two bottles of Lorazepam prescribed to two residents were found in the medication storage room despite the orders being discontinued. The Director of Nursing (DON) acknowledged that the medications should have been removed as per the facility's policy, which requires disposal within 72 hours of discontinuation. The DON admitted responsibility for auditing and removing controlled medications but failed to do so in this instance. Additionally, the facility did not administer medications accurately for a resident with intact cognition who was observed self-administering nebulizer treatments and keeping inhalers at the bedside without an assessment to self-administer. The resident's physician orders explicitly stated that medications should not be left at the bedside and should be observed when taken. Despite this, a Registered Nurse (RN) was observed leaving nebulizer medication at the resident's bedside, indicating that the facility had deemed the resident capable of self-administration without proper assessment. The DON later confirmed that the resident did not have an assessment to self-administer medications, highlighting a lapse in adherence to the facility's medication administration protocols.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional principles, as observed during a survey. Specifically, a resident (R32) was found to have two Ventolin HFA inhalers with their tops off on a bedside table, which were left unattended and out of view of staff. This observation was made during a three-day survey, where it was noted that the medications were not stored in locked compartments as required. The resident, who had intact cognition with a BIMS score of 15 out of 15, was managing their own medication, contrary to the physician's orders that required observation during medication administration. The resident, admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, pneumonia, and chronic respiratory failure with hypoxia, was observed using the inhaler without supervision. The Director of Nursing (DON) confirmed that the facility's expectation was for all medications to be stored in medication carts or storage rooms, and that the resident should not be using the inhalers freely in their room without nursing staff supervision. This discrepancy between the facility's policy and the resident's practice led to the deficiency noted by the surveyor.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility staff failed to conduct proper hand hygiene during resident care, specifically for one resident, R34. During an observation, a Certified Nursing Assistant (CNA) did not perform hand hygiene before donning gloves while providing peri care to the resident. The CNA was observed transferring the resident using a Hoyer lift, removing a urine-soiled brief, conducting peri care, and placing a new brief without performing hand hygiene before or after glove use. The CNA continued to handle the resident's clothing and bedding with contaminated gloves. The facility's policy, aligned with WHO guidelines, requires hand hygiene at specific moments, including before and after patient contact and after exposure to body fluids. The Director of Nursing confirmed the expectation for hand hygiene after contact with residents and their personal items or equipment.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plum City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mayo Clinic Health System - Lake City | 12.4 mi | ★★★★★ | 5 | 1 |
| Spring Valley Health And Rehab Center | 15 mi | ★★★★★ | 13 | 0 |
| Ellsworth Health Services | 16.3 mi | ★★★★★ | 6 | 0 |
| St Crispin Living Community | 17.4 mi | ★★★★★ | 15 | 1 |
| Gundersen St Elizabeth's Care Center | 18.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.