Plymouth Health Services

Inspectors wroteBased on interview, record review, and policy review, the facility did not follow its abuse policy or thoroughly investigate an allegation of abuse for 1 of 5 residents (R3) reviewed for abuse in a total sample of 14 residents. R3 reported that they felt physically and emotionally scared when they went to the dining room and thought was what happening was abuse. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on interview, record review, and policy review, the facility did not ensure 1 of 3 residents (R1) reviewed for falls from a total sample sample of 14 residents was transferred with a mechanical device in a safe manner. R1's care plan indicated they should be transferred with a Sit-to-Stand lift and the assitance of two staff. R1 was transferred with one staff and slipped from the lift to the floor.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident area remained at a safe, comfortable, and home-like temperature for 4 residents (R) (R5, R1, R4, and R6) of 8 sampled residents. On 6/12/26, the rooftop air conditioner that cooled R5, R1, R4 and R6's wing stopped working which resulted in room temperatures that were above 81 degrees Fahrenheit (F).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored and labeled appropriately in 1 of 1 medication cart and 1 of 1 medication storage room. This practice had the potential to affect more than 4 of the 17 residents residing in the facility. The medication cart contained resident medications with no use-by or open dates. R10's eye drops were not labeled with R10's name or instructions for use. On 8/19/25, a medication cart was left unlocked and unattended.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 2 of 8 staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for Licensed Practical Nurse (LPN)-E and Certified Nursing Assistant (CNA)-F.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Preadmission Screen and Resident Review (PASRR) was submitted for additional screening after a new antipsychotic medication was prescribed for 1 resident (R) (R12) of 5 sampled residents. On 8/27/24, R12 was prescribed Seroquel (an antipsychotic medication) for mood and behavior. The facility did not update R12's Level I PASRR Screen and did not submit for another Level II evaluation when R12 was prescribed a new medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 26 opportunities which resulted in an 7.69% medication error rate that affected 2 residents (R) (R7 and R16) of 4 residents observed during medication administration. On 8/19/25, R7 was administered the wrong cough medication. On 8/19/25, R16's scheduled 6:00 AM medication was administered at 7:36 AM.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility did not provide mechanically altered diets as ordered by the physician for 2 residents (R) (R4 and R5) of 2 sampled residents. Failure to provide diets as ordered by the physician places residents at risk for malnutrition, choking, and aspiration.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care was provided in accordance with a physician order for 1 resident (R) (R2) of 4 sampled residents. Staff did not provide a prescribed treatment for R2's wound and administered a treatment that was not ordered by the physician without the physician's knowledge.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R5) of 2 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R5 was provided catheter care in a manner that decreased the risk of infection.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R1, R2, and R5) of 5 sampled residents received the necessary care and services to prevent dehydration. The facility did not provide consistent hydration for R1, R2, and R5.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R1) of 5 sampled residents. R1 did not consistently receive scheduled medications timely as ordered by R1's physician.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision was provided for 1 Resident (R) (R2) of 11 sampled residents. On 6/19/24, facility staff discontinued R2's increased supervision after an allegation of sexual assault. The facility did not ensure adequate supervision was provided to prevent R2 from wandering and/or disrobing in front of other residents.

Inspectors wroteBased 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. Food items in unit refrigerators were not labeled or dated and/or were expired.

Inspectors wroteBased on staff interview and record review, the facility did not ensure court-ordered documents for guardianship and protective placement were obtained and/or on file for 1 resident (R) (R14) of 14 sampled residents. R14 had a court-ordered guardian. The facility did not have court documents for determination of permanent guardianship on file. In addition, the facility did not ensure court-ordered protective placement was completed for R14.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R7, R12 and R23) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not inform the State Long-Term Care Ombudsman for 2 (R7 and R23) of 3 residents reviewed for transfer/discharge. R7 was transferred to the hospital on 2/24/24. R7 was not provided with a written transfer notice. In addition, the Ombudsman was not notified of R7's transfer. R12 was transferred to the hospital on [DATE], 1/1/24, and 2/27/24. R12 was not provided with written transfer notices. R23 was transferred to the hospital on 6/11/24. R23 was not provided with a written transfer notice. In addition, the Ombudsman was not notified of R23's transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R7, R12 and R23) of 3 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R7 was transferred to the hospital on 2/24/24. The facility did not provide R7 with a bed hold notification. R12 was transferred to the hospital on [DATE], 1/1/24 and 2/27/24. The facility did not provide R12 with a bed hold notifications. R23 was transferred to the hospital on 6/11/24. The facility did not provide R23 with a bed hold notification

Inspectors wroteBased on staff interview and record review, the facility did not ensure the state mental health authority was promptly notified following a significant change in mental illness for 1 resident (R) (R12) of 6 sampled residents. R12 was admitted to the facility on [DATE] with a diagnosed mental illness (MI) with corresponding medication. The facility did not submit R12's Preadmission Screen and Resident Review (PASRR) Level I for a Level II Screen following R12's acute psychiatric hospital stay from 10/25/23 through 10/30/23.

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse reactions or side effects of high risk medications for 1 resident (R) (R3) of 5 residents reviewed for unnecessary medications. R3 was prescribed anti-convulsant medications for seizures. R3 did not have a care plan that addressed seizures or contained monitoring interventions for adverse reactions and side effects of the anti-convulsant medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure meal preferences were followed for 2 residents (R21 and R8) of 16 sampled residents. R21 stated the facility often lost R21's meal ticket which had R21's preferences for lunch on 6/24/24. During an observation of lunch service on 6/24/24, R21 did not receive R21's documented preferences. R8's care plan indicated R8 was legally blind and contained an intervention that staff should explain what was on R8's plate and where the food was located. The intervention was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during the provision of care for 1 resident (R) (R23) of 2 sampled residents. CNA (Certified Nursing Assistant)-I did not appropriately change gloves during the provision of care for R23.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide routine drugs and biologicals for 1 resident (R) (R1) of 3 residents reviewed for medication administration. R1 had an order for insulin lispro (a fast-acting medication to lower blood sugar) to be given three times a day. R1 did not receive one dose of insulin on 5/17/24 and received one dose outside of the scheduled administration time on 5/18/24.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 Resident (R1) of 1 resident was treated with respect and dignity regarding their preference for care. On 3/4/24, R1 told staff that R1 did not want to be woken up at night and checked for incontinence. R1's care plan was not updated and staff continued to check R1 at night.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a provider was notified when 1 Resident (R) (R1) of 3 residents experienced a change in condition. R1 experienced bladder spasms with increased pain on 2/23/24. Staff stated R1 needed to wait until 2/26/24 before something could be done. R1 was sent to the hospital on 2/24/24 and diagnosed with a urinary tract infection (UTI).

Inspectors wroteBased on staff and resident interview and record review, the facility did not document, investigate, or thoroughly resolve grievances for 2 Residents (R) (R1 and R2) of 8 residents. R1 expressed grievances on multiple occasions. The facility did not appropriately document, investigate, or thoroughly resolve the grievances. R2 expressed medication-related grievances on multiple occasions. The grievances were not investigated or resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for caregiver background checks. Certified Nursing Assistant (CNA)-D's last completed background check forms were dated 3/2/20. Cook (CK)-E's last completed background check forms were dated 3/17/20.

Inspectors wroteBased on staff and resident interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Resident (R) (R1) of 8 residents. R1 informed staff that R1 felt violated when Certified Nursing Assistant (CNA)-G checked R1's peri-area after R1 told CNA-G that R1 did not want to be checked, was not wet, and did not have a bowel movement. The facility did not report the allegation of abuse to the State Agency (SA) or local law enforcement.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R1) of 8 residents. R1 informed staff that R1 felt violated when Certified Nursing Assistant (CNA-G) checked R1's peri-area after R1 told CNA-G that R1 did not want to be checked, was not wet, and did not have a bowel movement. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R2) of 8 sampled residents. R2 did not consistently receive medication doses as ordered by R2's physician.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a self-medication assessment was completed for 1 Resident (R) (R14) of 1 resident observed with medication at the bedside. On 5/8/23, Surveyor observed 8 pills in varying sizes and colors on R14's bedside table. R14 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R14 could safely self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement documentation was obtained for 1 Resident (R) (R3) of 3 residents reviewed. R3s medical record did not contain protective placement documentation.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure all allegations of misappropriation were reported to the State Agency (SA) for 3 Residents (R) (R2, R3, and R11) of 3 sampled residents. On 4/1/23, R2's iPad was found in R3's possession. The facility did not report the allegation of misappropriation to the SA. On 4/23/23, an iPad, charger, and food were reported missing from R11's room and found in R3's room. The facility did not report the allegation of misappropriation to the SA.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure all allegations of misappropriation were thoroughly investigated for 3 Residents (R) (R2, R3 and R11) of 10 sampled residents. On 4/1/23, R2's iPad was found in R3's possession. The facility did not thoroughly investigate the allegation of misappropriation. On 4/23/23, an iPad, charger, and food were reported missing from R11's room. The facility found R11's iPad and charger in R3's possession. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on staff interview and record review, the facility did not provide foot care per standards of practice for 1 Resident (R) (R8) of 2 residents reviewed. R8 had a podiatry exam on 5/4/23 and a subsequent order to paint scabs/dry abrasions L (left) 2nd, 3rd, 4th, 5th toes daily with betadine until healed. The order was not contained or transcribed in R8's medical record.