Cycle 1
Health 2025-03-06 · Fire 2025-03-06
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Plymouth, WI
Rocky Knoll Health Care
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
N7135 Rocky Knoll Parkway, Plymouth, WI
(920) 893-6441
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
149
Certified beds
Average residents
141
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-08-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.06
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.56
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.19
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.80
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.70
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
1.08
CMS adjusted RN staffing hours
Adjusted total hours
5.25
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,518
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0111
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.98
Baseline 19.97% · Performance 18.20% · Measure score 6.98 · Achievement 6.98 · Improvement 5.53
Healthcare-associated infections
6.59
Baseline 6.38% · Performance 5.87% · Measure score 6.59 · Achievement 6.59 · Improvement 3.22
Total nurse turnover
4.05
Baseline 41.09% · Performance 47.13% · Measure score 4.05 · Achievement 4.05 · Improvement 0
Adjusted total nurse staffing
4.79
Baseline 4.89 hours · Performance 4.44 hours · Measure score 4.79 · Achievement 4.79 · Improvement 0
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 228 · Observed rate 9.21% · Lower 95% interval 7.5% |
| Discharge to community | 61.23% |
50.57%
10.7 pts better
|
Better than the National Rate · Eligible stays 215 · Observed rate 60% · Lower 95% interval 55.37% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 129 · Denominator 129 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 129 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 70 · Denominator 115 |
| Discharge mobility score | 41.74% |
50.94%
9.2 pts worse
|
Numerator 48 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 0.78% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 129 · Adjusted rate 1.01% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 3.28% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 12.55% |
8.2%
4.4 pts better
|
Numerator 33 · Denominator 263 |
| Staff flu vaccination coverage | 40.86% |
42%
1.1 pts worse
|
Numerator 143 · Denominator 350 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 60 · Denominator 115 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 83 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 14.81% |
25.2%
10.4 pts worse
|
Numerator 8 · Denominator 54 |
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 1.4 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.2
1.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
95.7%
3.4 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 99.1% · Q3 99.1% · Q4 100.0% · 4Q avg 99.1% |
| 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 | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.7% · Q3 3.5% · Q4 5.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
5.0%
3.1 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.0% · Q3 1.0% · Q4 2.9% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 4.1% · Q4 3.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
16.6%
0.3 pts worse
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 18.8% · Q3 17.0% · Q4 14.7% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
16.7%
4.4 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.0% · Q3 20.7% · Q4 20.8% · 4Q avg 21.1% · 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 | 23.8% |
21.1%
2.7 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 19.7% · Q3 27.6% · Q4 16.7% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
17.3%
5.2 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 29.8% · Q3 19.3% · Q4 11.8% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.9% |
2.3%
4.6 pts worse
|
1.0%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 8.0% · Q3 8.1% · Q4 4.9% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
3.0%
1.7 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.8% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
25.5%
7.4 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.5% · Q2 34.6% · Q3 24.1% · Q4 32.8% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
5.5%
4.1 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 0.8% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
86.8%
11.1 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 96.3% · Q3 98.1% · Q4 98.3% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
15.0%
10.4 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.3% · Expected 10.3% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 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 | 98.8% |
82.2%
16.6 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
22.7%
2.9 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 22.3% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-11-30 · Fire 2022-11-30
5 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-03-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-06
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-06
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 2025-03-27
D · Potential for more than minimal harm
2025-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-02-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-02-14
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-02-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-07
C · Minimal harm
2024-02-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-30
F · Potential for more than minimal harm
2022-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-19
F · Potential for more than minimal harm
2022-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-04
E · Potential for more than minimal harm
2022-11-30
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 2022-12-30
E · Potential for more than minimal harm
2022-11-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-11
F · Potential for more than minimal harm
2025-03-06
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 2025-03-28
E · Potential for more than minimal harm
2025-03-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
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 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-06
D · Potential for more than minimal harm
2024-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-07-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-02-14
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 2024-02-15
E · Potential for more than minimal harm
2024-02-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-14
F · Potential for more than minimal harm
2022-11-30
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-12-30
F · Potential for more than minimal harm
2022-11-30
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 2022-12-22
E · Potential for more than minimal harm
2022-11-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-11-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-30
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-12-26
Penalties and ownership
What sits behind the stars
Ownership
County Of Sheboygan
5% Or Greater Direct Ownership Interest · Organization
Fetterer, Jeremy
Operational/Managerial Control · Individual
Fredericks, Jeremy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Plymouth Health Services
Plymouth, WI
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Sheboygan Senior Community Inc
Sheboygan, WI
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Willowdale Health Services
New Holstein, WI
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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