Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Plymouth Health Services
Plymouth, WI · 50 certified beds · Last Life Safety survey August 20, 2025
CMS Certification Number 525685 · first certified January 2006
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Corporation
- Ownership changed December 1, 2019 (change of ownership)from PLYMOUTH CARE CENTER LLC
Position within WI
15 citations — more than 38% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2026. This facility’s last Life Safety survey was August 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 10, 2023 | 3 |
| June 26, 2024 | 3 |
| August 20, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-08-20 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-08-20 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-08-20 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2024-06-26 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2025-08-20 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2023-05-10 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-08-20 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2025-08-20 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 2
- Miscellaneous Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 20, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 19, 2025) |
June 26, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 29, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 29, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (July 29, 2024) |
May 10, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 2, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (June 2, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 2, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.