Cycle 1
Health 2025-01-08 · Fire 2025-01-08
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Plum City, WI
Plum City Care Ctr
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
301 Cherry Avenue West, Plum City, WI
(715) 647-2401
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Real Property Health Facilities
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.97
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,987
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9948
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.34
Performance 6.84% · Measure score 3.34 · Achievement 3.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.88
Baseline 43.14% · Performance 35.56% · Measure score 6.88 · Achievement 6.88 · Improvement 3.65
Adjusted total nurse staffing
2.33
Baseline 3.49 hours · Performance 3.74 hours · Measure score 2.33 · Achievement 2.33 · Improvement 0.6
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 6.26% |
| Discharge to community | 58.88% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 60% · Lower 95% interval 45.93% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 11.76% |
8.2%
3.6 pts better
|
Numerator 8 · Denominator 68 |
| Staff flu vaccination coverage | 64.58% |
42%
22.6 pts better
|
Numerator 62 · Denominator 96 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.6 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.2%
1.6 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.0% · Q3 6.2% · Q4 3.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
5.0%
4.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
4.9%
2.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 8.3% · Q3 12.5% · Q4 4.3% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
16.6%
3.3 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.0% · Q3 12.0% · Q4 8.7% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
16.7%
6.7 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q3 9.1% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.3% |
21.1%
1.8 pts better
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
17.3%
0.6 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 13.0% · Q3 26.1% · Q4 23.8% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
3.0%
1.9 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.2% · Q3 9.7% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
25.5%
2.6 pts better
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 26.6% · Q3 30.8% · Q4 10.3% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.5%
2.9 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.5% · Q3 3.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.3% |
86.8%
1.5 pts better
|
81.7%
6.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.6% · Q3 84.4% · Q4 78.4% · 4Q avg 88.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
15.0%
5.3 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 9.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
82.2%
11.9 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.2% |
22.7%
10.5 pts worse
|
23.9%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.2% · Observed 31.8% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-26 · Fire 2022-10-26
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-07
F · Potential for more than minimal harm
2023-12-07
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-12-04
E · Potential for more than minimal harm
2023-12-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-23
F · Potential for more than minimal harm
2022-10-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-25
F · Potential for more than minimal harm
2022-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-10-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-10-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-10-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
D · Potential for more than minimal harm
2023-12-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
F · Potential for more than minimal harm
2022-10-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-26
Penalties and ownership
What sits behind the stars
Ownership
Christina Jayne Penn Management Trust
5% Or Greater Direct Ownership Interest · Organization
Penn, Christina
5% Or Greater Indirect Ownership Interest · Individual
Haworth, Albert
Operational/Managerial Control · Individual
Haworth, Albert
Corporate Officer · Individual
Hutter, Carla
W-2 Managing Employee · Individual
Marsh, Dawn
Corporate Officer · Individual
Real Property Health Facilities Corp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Mayo Clinic Health System - Lake City
Lake City, MN
4-star overall rating with 3-star inspections with $32,139 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Spring Valley Health And Rehab Center
Spring Valley, WI
2-star overall rating with 2-star inspections with $27,690 in total fines with 14 recent health deficiencies
#3
Ellsworth Health Services
Ellsworth, WI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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