Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plymouth Health Services during CMS and state inspections, most recent first.
Unsafe Resident Room Temperatures During HVAC Failure: A rooftop AC unit serving one wing stopped working, and the affected resident rooms remained above the facility’s stated safe range during a period of extreme heat and humidity. Surveyor observations found multiple rooms in the mid-80s, while residents reported sweating, poor sleep, discomfort, anxiety, and worsening symptoms. Temporary hallway cooling units were not effective enough to keep the rooms within the facility’s target temperature range.
Inconsistent monitoring of dish machine temperatures and sanitizer logs was identified in the kitchen. Surveyors observed a dietary aide washing dishes while the rinse temp was below the manufacturer’s minimum, and record review showed repeated instances where required wash or rinse temps were not met. The dish machine logs also lacked a section for internal surface temp documentation, and sanitizer bucket logs were not consistently completed for PPM testing.
Improper Disposal of Garbage and Refuse: Surveyors observed two outside dumpsters with an open lid and an ajar rear door, exposing refuse and food. Open garbage bags and sliced bread were seen inside and outside the dumpster area, with bees and/or wasps hovering over the exposed food. The DM confirmed dumpster lids and doors should be securely shut, and the facility policy and Food Code required tight-fitting covers and proper refuse handling.
The facility did not maintain an infection prevention and control program that tracked employee illness or monitored signs and symptoms of illness and return-to-work dates. The DON stated staff call-ins were documented without a reason, and the VPS stated there was no policy or procedure for employee call-ins due to illness. Surveyors also noted COVID-19 positive staff and resident cases, while the facility provided resident infection line lists but no documentation of employee illnesses or call-ins.
Medication drugs and biologicals were not stored and labeled properly in a medication cart and medication storage area. A resident’s insulin and eye drops were found without open or use-by dates, and the resident’s eye drops and storage bag lacked the resident’s name and instructions for use. Staff also observed an unlocked, unattended medication cart, and an LPN confirmed it should not be left unlocked when unattended.
Incomplete caregiver background checks were cited after record review showed an LPN and a CNA did not have thorough screening completed as required by facility policy. The LPN’s DOJ and IBIS checks were dated after survey entry, and the CNA’s BID form was completed before turning 18, with no new BID form or DOJ/IBIS letters obtained after the birthday. Interviews confirmed background checks were expected before staff began working and that the CNA worked in the facility during the gap.
PASRR Not Updated After New Antipsychotic Medication: A resident with anxiety, depression, and labile mood had a PASRR Level I Screen and Level II evaluation completed after a change in condition, but when Seroquel was later prescribed for mood and behavior, the record did not show an updated PASRR or a new Level II review. The SW confirmed the PASRR should have been updated to reflect the new antipsychotic order.
Medication administration errors exceeded the allowed rate when two errors occurred during 26 observed opportunities. An RN gave a resident the wrong cough medication instead of the ordered PRN cough syrup, and another resident’s scheduled alprazolam ER dose was administered late. The DON verified both errors.
Two residents with severe cognitive impairment and swallowing difficulties were not served mechanically altered diets as ordered by their physicians. Instead of receiving soft, bite-sized foods, they were given hard, large pieces of pork loin and firm broccoli, contrary to their diet orders and care plans. Staff interviews revealed equipment issues and confusion about food preparation, and both the DON and RD confirmed the meals did not meet prescribed requirements.
A resident with multiple diagnoses, including diabetes and necrotizing fasciitis, did not receive the prescribed Clotrimazole cream due to unavailability. Instead, the facility used a house stock antifungal cream without a physician's order or notification. The MAR showed inconsistent entries, and the DON confirmed the lack of physician notification, violating the facility's Medication Reconciliation policy.
A resident with chronic kidney disease and urinary retention was observed with their catheter drainage bag uncovered and in contact with the floor, contrary to the facility's policy. The resident, who relied on staff for catheter care, was at increased risk of infection due to improper management of the catheter tubing and drainage bag. The Assistant Director of Nursing confirmed the failure to adhere to the facility's catheter care process.
The facility failed to provide consistent hydration for three residents, leading to concerns about inadequate water provision. Residents reported having to request water, with some not receiving it despite asking. Staff interviews revealed that water passes were not consistently completed due to staffing issues, affecting residents' hydration.
A resident in a LTC facility did not receive medications timely as per physician orders. The facility's liberalized medication pass times led to delays in administering medications, including insulin, which was supposed to be given with meals. The resident, who had intact cognition, reported receiving medications late, and the facility's records confirmed these delays.
A resident with moderate cognitive impairment and a history of wandering and disrobing was inadequately supervised after increased supervision was discontinued. The resident's care plan included a motion sensor for monitoring, but staff were unaware of its purpose or did not respond to it. Multiple instances of the resident being found naked outside their room were reported, indicating a lack of effective supervision.
The facility failed to maintain food safety and sanitation standards, affecting all 26 residents. Staff did not perform proper hand hygiene, and a staff member did not wear a beard net while plating food. The handwashing sink was unclean and used for non-handwashing purposes. Kitchen equipment and food items were improperly stored, with unlabeled and expired items found in refrigerators.
A facility failed to maintain necessary court-ordered documents for a resident with severe cognitive impairment, including permanent guardianship and protective placement. The resident's medical record lacked specific details required by state statutes, and the facility could not provide documentation for an annual review or protective placement filing upon admission.
The facility failed to provide required transfer notices to three residents who were hospitalized, and did not notify the State Long-Term Care Ombudsman for two of these cases. Despite the facility's policy, residents and their representatives did not receive written notices, and the Ombudsman was not informed. Interviews with staff revealed inconsistencies in following procedures, leading to these deficiencies.
The facility failed to provide bed hold notifications to three residents during hospital transfers, as required by policy. Despite the policy mandating notification at the time of transfer or within 24 hours, interviews revealed that neither the Nursing Home Administrator nor the Social Service Director ensured compliance. This resulted in residents with varying cognitive abilities not receiving the necessary notifications during their hospitalizations.
A facility failed to notify the state mental health authority after a resident with a diagnosed mental illness experienced a significant change in condition, including an acute psychiatric hospital stay. The resident's PASRR Level I indicated the need for a Level II Screen, which was not completed. The Social Service Director and Nursing Home Administrator confirmed the oversight.
A facility failed to monitor adverse reactions or side effects of high-risk medications for a resident with epilepsy and severely impaired cognition. The resident was prescribed anti-convulsant medications but lacked a care plan addressing seizures or monitoring interventions. The Nursing Home Administrator confirmed the absence of necessary monitoring interventions.
The facility failed to meet the dietary needs and preferences of two residents. One resident, with intact cognition, did not receive their meal preferences due to lost meal tickets, while another legally blind resident did not receive necessary assistance with food placement explanation. The Dietary Manager acknowledged issues with meal ticket management, and the meal ticket for the blind resident lacked necessary instructions, indicating a communication gap.
A facility failed to maintain an effective infection control program when a CNA did not change gloves during care for a resident with a history of neurogenic bladder, UTIs, and diabetes. Despite the facility's hand hygiene policy, the CNA used the same gloves throughout the care process, touching various surfaces and the resident's body, before finally removing the gloves and washing hands. The CNA acknowledged receiving hand hygiene education but forgot to apply it during the care.
A resident with type 2 diabetes did not receive a scheduled insulin dose and received another dose late, contrary to the facility's Medication Administration policy. The resident, with intact cognition, reported these issues, which were confirmed by the Medication Administration Audit Report and the facility's VPS.
Unsafe Resident Room Temperatures During HVAC Failure
Penalty
Summary
The facility did not ensure a resident area remained at a safe, comfortable, and home-like temperature for four residents on the second floor after the rooftop air conditioner serving that wing stopped working. The facility’s policy stated it would maintain comfortable and safe temperature levels and strive to keep common resident areas between 71 and 81 degrees Fahrenheit. The emergency plan for extreme heat directed staff to assess residents for distress or discomfort, consider relocating residents to a cooler part of the facility, provide cool washcloths and cooling fans, and encourage fluids. The rooftop air conditioner that cooled the 300 and 400 wings was reported not working on 6/12/26, but the repair process was delayed while the facility sought multiple bids and worked through vendor approval and corporate processes. During this period, the weather became increasingly hot and humid, with forecast heat indices reaching around 100 degrees and actual outdoor temperatures rising into the 80s and 90s. The facility obtained portable air conditioning units for the hallway, but staff and residents reported they were not effective enough to cool the affected rooms. The maintenance director stated the hallway units were installed on 6/29/26, while other documentation and interviews gave different dates for when temporary units were ordered, delivered, and installed. Surveyor observations on 7/1/26 found the affected resident rooms were above the facility’s stated temperature range. R5’s room measured 81.5 degrees Fahrenheit, and R5 said the room was terrible without a fan and that the heat had been ongoing. R1’s room measured 84.4 degrees Fahrenheit, and R1 reported the air conditioning had not been running for more than a week, that the room became progressively warmer over the weekend, and that the heat worsened anxiety and multiple sclerosis symptoms. R4’s room measured 86.8 degrees Fahrenheit, and R4 reported trouble sleeping, feeling sick, and having diarrhea due to the heat. R6’s room measured 85.7 degrees Fahrenheit, and R6 stated they woke up sweating every night. Interviews also showed residents were offered ice water, popsicles, washcloths, room changes, and temporary cooling measures, but the rooms remained hot during the surveyor’s observations.
Inconsistent Monitoring of Dish Machine Temperatures and Sanitizer Logs
Penalty
Summary
Kitchen equipment was not monitored appropriately to ensure food safety. During observation and record review, the facility’s hot water sanitizing dish machine was found to be operating below the manufacturer’s required temperatures at times, and staff did not consistently verify that the minimum wash and rinse temperatures were reached before dishware was used again. The Dietary Manager stated the facility follows the Federal and State Food Codes and that staff were supposed to monitor temperatures before washing dishes three times per day, but the manufacturer’s data plate showed a minimum wash temperature of 160 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit, which differed from the manager’s understanding of the machine requirements. Surveyors observed a dietary aide washing dishes while the machine’s rinse temperature read 176 degrees Fahrenheit, and the aide did not monitor to ensure the minimum temperature was reached or rewash the dishware. Review of dish machine logs from May through August 2025 showed multiple occasions when required temperatures were not met, including 35 of 93 occurrences in May, 16 of 90 in June, 37 of 93 in July, and 12 of 58 in August. The facility’s logs also did not include a place to document internal surface temperatures, even though the Dietary Manager stated staff should be documenting them. In addition, sanitizer bucket logs showed that testing and documentation of sanitizer PPM was not consistently completed, with 27 of 124 occasions in May lacking documentation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not properly disposed of in the outside dumpster area. On 8/18/25, surveyors observed two dumpsters by the receiving dock doors: one had an open lid with exposed refuse, and the other had a rear sliding door that was ajar. Inside that dumpster, several garbage bags were open with exposed food, and a bag containing sliced bread was also observed outside the dumpster on the receiving dock ledge behind the open door. Several slices of bread had been removed from the bag and were on the cement, with bees and/or wasps hovering over the exposed food and inside the dumpster. During interview, the Dietary Manager verified that dumpster lids and doors should be securely shut. The facility policy stated garbage and refuse would be collected and disposed of in a safe and efficient manner, and that the Dining Services Director would coordinate with Maintenance to keep the exterior dumpster area free of rubbish or debris and ensure appropriate lids were provided for all containers. The Wisconsin Food Code cited in the report required outside receptacles used with materials containing food residue to have tight-fitting lids, doors, or covers and to be designed and constructed to minimize debris accumulation and insect and rodent attraction.
Infection Surveillance Program Not Tracking Employee Illness
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. Staff interview and record review showed the facility did not track employee call-ins due to illness and did not monitor signs and symptoms of illness or return-to-work dates. The facility's Infection Surveillance policy dated 3/8/23 states that infection surveillance is a core activity of the infection prevention and control program and that employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks. From 8/18/25 to 8/20/25, surveyors reviewed the facility's infection surveillance program and found it did not include tracking employee call-ins due to illness or monitoring signs and symptoms of illness and return-to-work dates. The facility provided resident line lists with infection data and tracking and trending information, but did not provide documentation of employee illnesses or employee call-ins due to illness for January 2025 to the present. Surveyors noted a COVID-19 positive staff member in April 2025 and a COVID-19 positive staff member and resident on 8/20/25. The DON stated the facility does not keep track of employee call-ins due to illness and that employees do not have to give a reason for calling in, while the VPS stated the facility does not have a policy or procedure for employee call-ins due to illness and does not monitor employees' signs and symptoms of illness or return-to-work dates.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in the medication cart and medication storage area. During medication pass, the cart contained multiple medications for R10 with no open or use-by dates, including a NovoLog FlexPen injector, dorzolamide hydrochloride/timolol maleate ophthalmic solution, cyclosporine ophthalmic emulsion, brimonidine tartrate ophthalmic solution, and prednisolone acetate ophthalmic suspension. RN-M confirmed that R10’s eye drops were not labeled with open dates, and the DON confirmed that insulins and eye drops should be labeled with open dates. R10 was admitted with diagnoses including diabetes, MSSA, glaucoma, and legal blindness. While preparing to administer dorzolamide hydrochloride/timolol maleate ophthalmic solution to R10, the surveyor observed that the eye drop bottle and storage bag did not have R10’s name, an open date, or instructions for use. RN-M verified that the eye drops and storage bag did not contain a label or resident identifier. In addition, a medication cart was observed unlocked and unattended in front of the nurses’ station, and an LPN confirmed that the medication cart should not be unlocked when unattended.
Incomplete caregiver background checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after staff interview and record review showed the facility did not complete thorough caregiver background checks for 2 of 8 staff reviewed. The facility’s Abuse, Neglect and Exploitation policy stated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks would be conducted on potential employees and contracted temporary staff, with documentation maintained to show the screening occurred. Record review on 8/19/25 showed LPN-E’s hire date by corporate was 10/30/24 and the transfer to the facility occurred on 6/22/25, but the BID form was dated 6/23/25 and the DOJ criminal background check letter and IBIS letters were both dated 8/18/25, after the survey team entered the facility. CNA-F’s hire date was 1/2/25, but the BID form on file was dated 8/23/23, before CNA-F turned 18 on 7/5/25, and the facility did not obtain a new BID form after that date or obtain DOJ or IBIS letters. The NHA stated background checks should be completed before staff start at the facility, and the BOM confirmed LPN-E did not have a DOJ or IBIS letter on file before 8/18/25 and that CNA-F worked in the facility between 7/5/25 and 8/18/25 without a new BID form after turning 18.
PASRR Not Updated After New Antipsychotic Medication
Penalty
Summary
The facility did not ensure a Preadmission Screen and Resident Review (PASRR) was submitted for additional screening after a new antipsychotic medication was prescribed for one resident. The resident was admitted with diagnoses including malignant carcinoid tumor of the small intestine, anxiety disorder, depression, and labile mood, and had a BIMS score of 15 out of 15 on the most recent MDS, indicating intact cognition. The resident also had a guardian responsible for healthcare decisions. The resident’s PASRR Level I Screen had previously been updated because of a change in condition and sent for a Level II evaluation, which was completed and documented the resident’s mental illness diagnoses and medications including Zoloft, Xanax, and Depakote. After the resident was prescribed Seroquel for mood and behavior, the medical record did not include an updated PASRR Level I Screen or a new Level II evaluation. The Social Worker responsible for completing PASRR Level I Screens and submitting them for Level II evaluation stated that resident reviews are completed every 3 months and staff notify the Social Worker when there is a change in condition or a new medication or diagnosis. The Social Worker confirmed the PASRR Level I Screen should have been updated to include the new Seroquel order and submitted for a Level II evaluation.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 26 opportunities, resulting in a 7.69% medication error rate that affected 2 residents, R7 and R16, of 4 residents observed. The facility’s Medication Administration General Guidelines policy, dated 1/25, states that staff must review and confirm medication orders on the MAR before administration, administer medications in accordance with prescriber orders, and administer medications within 60 minutes of the scheduled time. For R7, who had diagnoses including diabetes, congestive heart failure, chronic kidney disease, and dysphagia, the MAR contained an order for guaifenesin-dextromethorphan liquid 100-10 mg/5 ml, 5 ml by mouth every 6 hours as needed for cough. During observation, RN-M prepared and administered 5 ml of dextromethorphan hydrobromide 20 mg/guaifenesin 200 mg/phenylephrine hydrochloride 10 mg liquid from house stock, which was not the ordered medication. The DON later verified the wrong medication had been administered. For R16, who had diagnoses including multiple sclerosis, anxiety, and depression, the MAR ordered alprazolam ER 0.5 mg twice daily at 0600 and 1800. During observation, RN-M administered the 0600 dose at 7:31 AM, and the DON verified that the scheduled 6:00 AM dose was given late.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
Two residents with severe cognitive impairment and a history of swallowing difficulties were not provided with mechanically altered diets as ordered by their physicians. Both residents had physician orders and care plans specifying an L3/Advanced texture diet, which requires foods to be soft, moist, and cut into bite-sized pieces less than one inch. During meal service, both residents received cubed pork loin that was hard and larger than one inch, as well as firm broccoli spears, instead of the required ground meat and soft, mashed broccoli. Tray cards for both residents indicated the correct diet, but the meals served did not comply with these orders. Staff interviews revealed that the blender used to prepare mechanically altered foods was broken, and there was confusion among dietary staff regarding the use of available kitchen equipment. The Dietary Manager confirmed that the food served did not meet the required texture and size, and the Director of Nursing acknowledged that the diet cards should have been followed, especially given the residents' severe dementia and eating difficulties. The Registered Dietitian also confirmed the requirements for the L3/Advanced diet. These failures resulted in the residents not receiving the prescribed diet texture and consistency.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to provide care in accordance with a physician's order for a resident who was admitted with multiple diagnoses, including diabetes, morbid obesity, anxiety, Fournier's disease, and necrotizing fasciitis. The resident had a physician order for Clotrimazole External Cream 1% to be applied twice daily to the right inner thigh for erythema. However, the facility did not administer the prescribed treatment consistently due to the medication being unavailable. Instead, the facility used a house stock antifungal cream, DermaFungal Antifungal Cream 2% Miconazole Nitrate, without obtaining a physician's order or notifying the physician of the change. The Medication Administration Record (MAR) for the resident showed multiple entries indicating the unavailability of the prescribed medication and the use of an alternative cream without proper documentation or physician notification. The Director of Nursing confirmed that the staff did not update the physician or the MAR with the change in medication, which was against the facility's Medication Reconciliation policy. This policy requires that any new orders be transcribed accurately and verified by a second nurse, and that any changes in medication be communicated to the physician.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to a resident, leading to an increased risk of urinary tract infections. The resident, who had a history of type 2 diabetes with chronic kidney disease, urinary retention, and benign prostatic hyperplasia, was observed multiple times with their catheter drainage bag uncovered and in contact with the floor. Despite the facility's policy requiring catheter bags to be covered and kept off the floor, the resident's catheter tubing and drainage bag were improperly managed, compromising infection control measures. The resident, who had moderately impaired cognition, relied on nursing staff for catheter care. However, the staff did not adhere to the facility's catheter care policy, as confirmed by the Assistant Director of Nursing (ADON). The ADON was initially unsure of the policy regarding covering catheter bags but acknowledged that the catheter bags and tubing should not be on the floor. The failure to follow the facility's catheter care process was confirmed during an interview with the ADON, highlighting a deficiency in the care provided to the resident.
Inadequate Hydration for Residents
Penalty
Summary
The facility failed to ensure adequate hydration for three residents, R1, R2, and R5, as observed by surveyors. R1, who had intact cognition, reported that the water cup on their bedside table was from two days ago and that water was not provided unless requested. Despite raising this issue in care conferences, R1 continued to experience inadequate water provision. R2, also with intact cognition, stated that they had to ask for water, and the water cup on their bedside table was from the previous night. R5, with moderately impaired cognition, reported that their water cup, containing less than 100 cc of water, was from the previous day, and they had not received water despite requesting it that morning. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were expected to complete water passes each shift, but this was not consistently done due to staffing issues. CNA-F admitted to often not having enough time to complete water passes, while CNA-D confirmed that water passes were sometimes missed due to staffing constraints. Residents who could not ask for water were only provided with fluids during meals and medication administration, indicating a systemic issue in ensuring consistent hydration for all residents.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure the timely administration of medications for a resident, identified as R1, who was part of a sample of five residents. R1, who had intact cognition and was responsible for their healthcare decisions, reported receiving scheduled medications late. The facility's Medication Administration policy required medications to be administered within 60 minutes of the scheduled time, except for those tied to meal times. However, the facility had liberalized medication pass times, which contributed to the delay in medication administration. R1's medical record indicated several physician orders, including medications for diabetes, anxiety, and nerve pain, as well as blood glucose monitoring and insulin administration. The surveyor's review of R1's Medication Administration Record (MAR) and Medication Admin Audit Report revealed multiple instances where medications were administered late. For example, insulin lispro, which was to be given with meals, was often administered well after the scheduled meal times, and blood sugar levels were not obtained as ordered before meals. Interviews with the facility's Vice President of Success (VPS-E) and the Nursing Home Administrator (NHA-A) confirmed the discrepancies in medication administration times. VPS-E acknowledged that R1's insulin should have been administered with meals as ordered and verified that the medications were indeed given late. The facility's meal times did not align with the liberalized medication pass times, leading to the late administration of medications, which was not in accordance with the physician's orders or the facility's policy.
Inadequate Supervision and Monitoring of Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision for a resident with moderate cognitive impairment, who had a history of wandering and disrobing in public. After an allegation of sexual assault, increased supervision for the resident was discontinued, and the facility did not ensure that the resident was adequately monitored to prevent wandering and disrobing incidents. The resident's care plan included interventions such as frequent checks, encouraging activities outside the room, and using a motion sensor to monitor wandering. However, the motion sensor was not effectively monitored, as staff were unaware of its purpose or did not respond to it. Multiple staff members, including CNAs and LPNs, reported instances where the resident was found naked outside their room, indicating a lack of supervision. The motion sensor, intended to assist in monitoring the resident, was not consistently used or understood by all staff, particularly agency staff. Interviews with staff and other residents confirmed that the resident had been seen naked on several occasions, and the facility administration was not aware of these incidents. The lack of formal education on the use of the motion sensor contributed to the deficiency in supervision.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, which had the potential to affect all 26 residents residing in the facility. Staff members did not perform proper hand hygiene before donning gloves, while passing silverware, before touching ready-to-eat food, and while doing dishes. Additionally, a staff member did not wear a beard net while plating food. These actions were observed during meal service, where staff members were seen touching the tips of knives with bare hands and failing to wash hands before donning gloves or after handling soiled equipment. The handwashing sink in the nourishment room on a resident unit was not maintained in a clean condition and appeared to be used for purposes other than handwashing. The sink area contained a sponge with brown edges, a dry, crusted rag, and chunks of food in the drain. The cabinet underneath the sink was in poor condition, with crumbling fiberboard and dark areas that appeared to be mold or mildew. The sink did not have signage indicating it was for handwashing, and the Dietary Manager was unaware of the condition of the cabinet. Kitchen equipment, refrigerators, an ice machine, and dishes were not stored clean, in a down-facing position, covered appropriately, or stored six inches off the floor. Unlabeled and undated food items, as well as expired items, were found in unit refrigerators. The dining room refrigerator contained unlabeled fruit plates and resident meals, while the nourishment room refrigerator had expired cottage cheese and prune juice containers without expiration dates. The Dietary Manager confirmed that food items should be labeled and disposed of when expired.
Failure to Maintain Guardianship and Protective Placement Documentation
Penalty
Summary
The facility failed to ensure that court-ordered documents for guardianship and protective placement were obtained and maintained for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including cerebral palsy and mild cognitive impairment, had a court-appointed guardian. However, the facility did not have the necessary court documents on file to confirm the determination of permanent guardianship or the completion of a court-ordered protective placement, as required by Wisconsin State Statutes. During the survey, it was found that the resident's medical record contained a court document indicating a standby guardian and the need for protective placement, but it lacked specific details such as the name of the facility, the date of protective placement, or the last review date. The Social Services Director and Nursing Home Administrator confirmed the absence of documentation for an annual review of protective placement and permanent guardianship. The facility was unable to provide additional documentation to show that protective placement was filed when the resident was admitted.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide timely and adequate transfer notices to three residents who were hospitalized, as required by their own policy and regulatory standards. Resident 7, who had moderate cognitive impairment, was transferred to the hospital following a fall with injury but did not receive a written transfer notice. Additionally, the State Long-Term Care Ombudsman was not informed of this transfer. Resident 12, with intact cognition, was transferred to the hospital on three separate occasions for various medical reasons, including a possible stroke and pre-planned medical testing, yet did not receive written transfer notices for any of these events. Resident 23, who also had intact cognition, was transferred to the hospital with stroke-like symptoms but did not receive a written transfer notice. Furthermore, the Ombudsman was not notified of this transfer either. The facility's policy mandates that in the event of emergency transfers, a Transfer Form should be completed and provided to the resident or their representative, and the Ombudsman should be notified via a monthly list. However, these procedures were not followed for the residents in question. Interviews with facility staff, including the Nursing Home Administrator and the Social Service Director, revealed that the responsibility for issuing transfer notices was not consistently upheld. The Nursing Home Administrator confirmed that transfer notices were not completed, and the Social Service Director acknowledged that they had not been submitting the required monthly notifications to the Ombudsman. This lack of adherence to policy resulted in the failure to properly notify residents and their representatives of transfers, as well as the failure to inform the Ombudsman of such events.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to three residents during their transfers to the hospital, as required by their policy. Resident 7, who had moderately impaired cognition, was transferred to the hospital following a fall with injury and was not given a bed hold notification. Resident 12, with intact cognition, was transferred to the hospital on three separate occasions for various medical reasons, including a possible stroke and pre-planned medical testing, but did not receive any bed hold notifications. Resident 23, also with intact cognition, was transferred to the hospital with stroke-like symptoms and similarly did not receive a bed hold notification. The facility's policy mandates that a bed hold notice should be provided to the resident or their representative at the time of transfer or within 24 hours. However, interviews with the Nursing Home Administrator and the Social Service Director revealed that the process was not followed. The Nursing Home Administrator confirmed that bed hold notices were not provided and stated that nurses should provide at least a verbal notice during emergent transfers. The Social Service Director acknowledged the responsibility to provide bed hold notices but admitted to not completing them, indicating a lapse in the facility's adherence to its own policy.
Failure to Notify State Mental Health Authority After Resident's Significant Change
Penalty
Summary
The facility failed to ensure the state mental health authority was promptly notified following a significant change in mental illness for a resident, identified as R12, who was part of a sample of six residents. R12 was admitted to the facility with a diagnosed mental illness and corresponding medication. Despite R12's acute psychiatric hospital stay from October 25, 2023, through October 30, 2023, the facility did not submit R12's Preadmission Screen and Resident Review (PASRR) Level I for a Level II Screen, which is required following such significant changes in condition. R12's medical record indicated a serious mental illness with symptoms necessitating a Level II Screen, which was not completed. The resident had been admitted to a psychiatric hospital for acute inpatient behavioral health due to suicidal threats and returned to the facility with medication changes. During an interview, the Social Service Director and Nursing Home Administrator confirmed that a PASRR Level II Screen was not completed for R12, acknowledging that it should have been done following the resident's original admission and after the psychiatric hospital stay.
Failure to Monitor Adverse Reactions for High-Risk Medications
Penalty
Summary
The facility failed to monitor for adverse reactions or side effects of high-risk medications for one resident, identified as R3, who was reviewed for unnecessary medications. R3 was prescribed anti-convulsant medications for seizures but did not have a care plan addressing seizures or monitoring interventions for adverse reactions and side effects of these medications. R3 was admitted with a diagnosis of epilepsy and had a severely impaired cognition, as indicated by a BIMS score of 3 out of 15. The medical record showed prescriptions for Gabapentin, Levetiracetam, and Primidone, but lacked a care plan for seizures or monitoring interventions. The Nursing Home Administrator confirmed the absence of monitoring interventions, acknowledging that they should have been in place.
Failure to Follow Meal Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure meal preferences and dietary needs were consistently met for two residents, R21 and R8, as observed by surveyors. R21, who has intact cognition and a regular diet order, reported that the facility often lost their meal ticket, which included their meal preferences. During a lunch service, R21 did not receive their documented meal preferences, specifically receiving corn, which they had crossed off due to it upsetting their stomach. The Dietary Manager acknowledged issues with lost meal tickets and confirmed that residents should receive their preferences and ordered diets. R8, who is legally blind and has moderately impaired cognition, did not receive the necessary assistance during meal service. Their care plan required staff to explain the placement of food on their plate, but this intervention was not consistently followed. During an observation, staff did not inform R8 about the food on their plate or its location, which R8 confirmed was important to them to avoid eating items they dislike. The meal ticket for R8 did not indicate their visual impairment or the need for food placement explanation, highlighting a gap in communication between dietary staff and care plans.
Inadequate Infection Control Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper glove use by a Certified Nursing Assistant (CNA) during the provision of care for a resident. The facility's Hand Hygiene Policy, dated November 2, 2022, mandates that all staff perform proper hand hygiene procedures, including changing gloves when necessary, to prevent the spread of infection. However, during an observation on June 26, 2024, a surveyor noted that CNA-I did not change gloves while providing peri and catheter care for a resident, identified as R23. This resident had a history of neurogenic bladder, urinary tract infections, and diabetes, and required extensive assistance with bed mobility, transfers, and hygiene. During the observed care, CNA-I and another CNA, CNA-J, initially washed their hands and donned gloves. However, CNA-I failed to change gloves after touching various surfaces and items, including the resident's peri area, Foley catheter tubing, and buttocks, as well as multiple surfaces in the resident's bathroom. CNA-I continued to use the same gloves throughout the care process, which included touching the resident's side, clean brief, and bed, before finally removing the gloves and washing hands. CNA-I later confirmed in an interview that they did not change gloves during the care and acknowledged having received hand hygiene education at the facility but forgot to apply it during the care for R23.
Failure in Timely Insulin Administration
Penalty
Summary
The facility failed to provide routine pharmaceutical services for a resident, specifically in the administration of insulin lispro, a fast-acting medication used to manage blood sugar levels. The resident, who was diagnosed with type 2 diabetes among other conditions, did not receive a scheduled dose of insulin on one occasion and received another dose outside the prescribed time frame. The facility's Medication Administration policy requires medications to be administered at specific times relative to meals and bedtime, but this protocol was not followed in the case of the resident. The resident, whose cognition was fully intact, reported not receiving the 6:00 PM insulin dose on one day and receiving the 10:00 AM dose late on the following day. The Medication Administration Audit Report confirmed these discrepancies, showing no record of the 6:00 PM dose being administered and the 10:00 AM dose being given at 3:43 PM. The facility's Vice President of Success verified the lack of documentation for the missed dose and the late administration of the other dose, confirming the surveyor's findings.
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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 Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Knoll Health Care | 3.9 mi | ★★★★★ | 6 | 0 |
| Sheboygan Senior Community Inc | 9.9 mi | ★★★★★ | 16 | 0 |
| Sheboygan Health Services | 11.1 mi | ★★★★★ | 7 | 0 |
| Edenbrook Sheboygan | 11.2 mi | ★★★★★ | 7 | 2 |
| Sheboygan Progressive Health Services | 12 mi | ★★★★★ | 3 | 1 |
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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 August 2026) and official state health department websites.