Deficiency Index

Plymouth Health Services

Plymouth, Wisconsin · CCN 525685

38 surveys since 2010. The first finding at harm level was recorded in 2018.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
157
Surveys
38
Harm or worse
4
Immediate jeopardy
1
The record, 2010–2026
’10’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy1

Findings at the most serious level CMS records.

Beyond CMS’s monthly file27/38

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
50
Ownership
For profit - Corporation
Chain
NORTH SHORE HEALTHCARE
County
Sheboygan
Medicare-certified since
2006

CMS ratings

Overall
1
Health inspection
2
Staffing
3
Quality measures
1

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded more weighted findings than most of its peer group.

Weighted by harm level, against 92 for-profit facilities with fewer than 66 beds in Wisconsin.

Last survey on record

Jul 8, 2026

124 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.833.73
Registered-nurse hours per resident day1.03—
Annual nurse turnover73.1%45.7%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD3181.6%E25.3%F513.2%
No harm, potential for minimalA—B—C—
CMS’s current file: 38 of the 157 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6103×

    Respond appropriately to all alleged violations.

  • F7553×

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • F8123×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • F6072×

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • F6092×

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

In the surveyor’s words

From the most serious findings on record at Plymouth Health Services, in the surveyor’s own words.

  • No harm, potential for more than minimal, widespreadF812Aug 20, 2025

    Based on observation, staff interview, and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 17 residents residing in the facility.The dishwasher did not meet the minimum wash and rinse temperatures to prevent the spread of foodborne illness. In addition, staff did not document internal surface temperatures.Staff did not consistently complete documentation logs for parts per million (PPM) of the sanitizing solution.Findings include:On 8/18/25 at 9:58 AM, Surveyor interviewed Dietary Manager (DM)-G and Regional Manager (RM)-H who indicated the facility follows the Federal and State Food Codes (whichever is stricter).Mechanical Warewashing:The 2022 Food and Drug Administration (FDA)… […]

  • No harm, potential for more than minimal, widespreadF814Aug 20, 2025

    Based on observation, staff interview, and record review, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all 17 residents residing in the facility.On 8/18/25, the lid on an outside refuse dumpster was open and the rear sliding door on another dumpster was ajar with exposed food pulled out. In addition, insects, including wasps and/or bees, were observed inside and outside the dumpster near the exposed food.Findings include:On 8/18/25 at 9:58 AM, Surveyor interviewed Dietary Manager (DM)-G and Regional Manager (RM)-H who indicated the facility follows the Federal and State Food Codes (whichever is stricter).The facility's Dispose of Garbage and Refuse policy, dated August 2017, indicates all… […]

  • No harm, potential for more than minimal, widespreadF880Aug 20, 2025

    Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 17 residents residing in the facility.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, indicates: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. […]

  • No harm, potential for more than minimal, widespreadF812Jun 26, 2024

    Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. Staff did not perform proper hand hygiene prior to donning gloves, while passing silverware, prior to touching ready to eat food, and while doing dishes. Staff did not wear a beard net while plating food. The handwashing sink in the nourishment room on a resident unit was not in clean condition and appeared to be used for things other than handwashing. Kitchen equipment, refrigerators, an ice machine, and dishes were not stored clean, in a down facing position, covered appropriately, and/or stored 6 inches off the floor. […]

  • No harm, potential for more than minimal, widespreadF812May 10, 2023

    Based on observation, staff interview, and record review, the facility did not store, prepare, and serve food in accordance with professional standards for food service safety. This practice had the potential to affect multiple residents residing in the facility. Food items in a dry storage area and prep cooler were open and undated. Temperature monitoring logs for the prep cooler and freezer contained missing entries. Findings include: Per ServSafe Essentials: Fifth Edition (2008), under the section titled Monitoring: Check cooler temperatures at least once during each shift. Place hanging thermometers inside the cooler to make this task easy to do. […]

Read 24 findings in full →The most serious and the most recent: 24 of 157 on record.

Every survey on record

FindingsAt actual harm or above

  • Jul 8, 2026Complaint2 findings
  • Jul 1, 2026Complaint1 finding
  • Aug 20, 2025Standard7 findings
  • Jul 10, 2025Complaint1 finding
  • Oct 9, 2024Complaint1 finding
  • Aug 26, 2024Complaint3 findings
  • Jul 31, 2024Complaint1 finding
  • Jun 26, 2024Standard8 findings
Show the 30 earlier surveys
  • Jun 10, 2024Complaint1 finding
  • Mar 19, 2024Complaint7 findings
  • May 10, 2023Standard and complaint6 findings
  • Mar 29, 2023Complaint1 finding
  • May 11, 2022Standard14 findings
  • Sep 23, 2021Complaint2 findings
  • Sep 14, 2021Complaint4 findings
  • Aug 23, 2021Complaint5 findings
  • May 5, 2021Standard12 findings
  • Feb 24, 2021Complaint1 finding
  • Dec 15, 2020Complaint2 findings
  • Oct 6, 2020Complaint1 finding
  • Sep 2, 2020Complaint1 finding
  • Jul 31, 2019Standard11 findings
  • Jul 19, 2019Complaint3 findings · 2 harm
  • Apr 24, 2019Complaint1 finding
  • Aug 20, 2018Complaint1 finding
  • Jul 25, 2018Standard and complaint9 findings · 2 harm
  • Dec 11, 2017Complaint2 findings
  • May 10, 2017Standard and complaint11 findings
  • Jun 13, 2016Complaint3 findings
  • Apr 6, 2016Standard2 findings
  • Mar 23, 2015Standard and complaint2 findings
  • Oct 22, 2014Complaint1 finding
  • Mar 20, 2014Standard7 findings
  • Jan 29, 2013—5 findings
  • Feb 9, 2012—6 findings
  • May 10, 2011—1 finding
  • Feb 15, 2011—7 findings
  • Nov 11, 2010—4 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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