Plum City Care CTR

In the surveyor’s words

From the most serious findings on record at Plum City Care CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 8, 2025

  Based on observation, interview and record review, the facility did not ensure that food was stored, prepared, distributed, and served food in accordance with professional standards for food service safety. The facility did not label opened dry goods with an open date to ensure food safety for residents. This has the potential to affect all 37 of 37 residents (R) residing in the facility. Findings include: Facility policy titled, Food Storage Standards revised November 2024, states, The dietary director shall ensure that standards for refrigerated, frozen, and dry foods are followed . Policy: follow the criteria below for all types of food storage . 3. Criteria for Dry Food Storage: . A dry food storage timeline chary is available and followed. […]

• No harm, potential for more than minimal, widespreadF812Oct 26, 2022

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in a safe and sanitary manner. This has a potential to affect all 39 residents. Kitchen staff did not test the dishwashing machine's chemical sanitization solution to ensure it is maintained at the correct concentration to prevent a potential chemical contamination of the food served to the residents. This is evidenced by: The following are general recommendations according to the U.S. […]

• No harm, potential for more than minimal, patternF686Jan 8, 2025

  Based on observations, interviews and record reviews, the facility did not ensure 4 of 4 residents (R5, R34, R28 and R3) reviewed for moderate to high risk of Pressure Injury (PI) development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. -R5 is at moderate risk for the development of PIs. R5 was observed for 5 hours and 13 minutes sitting in a Broda chair without staff offering or attempting to offload body surface. -R34 was admitted with multiple PIs and was at risk for PI development. The facility did not reposition R34 for several hours and did not provide repositioning to off-load the coccyx and hip as ordered. -R28 was at risk for PI development. […]

• No harm, potential for more than minimal, isolatedF580Apr 22, 2026

  Based on interview and record review, the facility did not ensure staff consulted with the resident's physician per physician orders when laboratory values are out of parameters for 1 of 12 residents (R22) reviewed.The facility did not notify the provider when R22's blood sugars were outside of parameters per physician order.This is evidenced by:Facility policy titled, Physician Notification - Consultation Parameters, with a reviewed date of 12/2023, states: .Non-immediate Notification: The attending physician should be informed of the event during normal office hours, and generally no later than the next regular office day.R22 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus.R22's physician orders include:Blood glucose checks every other day AM. […]

• No harm, potential for more than minimal, isolatedF628Apr 22, 2026

  Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the Wisconsin Bed Hold Notice and did not include the specific reason for transfer. This has the potential to affect all 39 residents.R4 received a bed hold notice with no daily rate documented and transfer notice did not specify reason for transfer.This is evidenced by:R4 was admitted to the facility on [DATE].On 10/11/25, R4 was transferred to the hospital. The WI Bed-Hold was signed by R4 and did not include the daily rate to hold R4's bed. The Transfer Notice noted reason for transfer was due to R4 requesting a transfer. No specific reason for transfer was documented.On 01/08/26, R4 was transferred to the hospital. […]