Plymouth Rehabilitation & Health Care Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required food items to be served in separate containers, the Facility failed to ensure he/she was free from incidents/accidents resulting in serious injury. On 06/13/26, Resident #1's mashed potatoes were portioned and served to him/her in a covered container with an unvented (without steam hole, holds temperature of food item longer) lid, when Resident #1 attempted to eat the mashed potatoes, they were too hot so he/she spit them out and they landed on his/her right thigh, which caused him/her to sustain a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the top of his/her right thigh, which required daily treatment. Findings Include: [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#10), out of a total sample of 29 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, for Resident #10, the facility failed to implement treatments from the wound consultant physician for a Stage 4 pressure ulcer (full-thickness loss of skin) on the left ischium/buttock.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were labeled and stored in accordance with acceptable professional standards. Specifically, the facility failed to:1. Ensure Resident #50's Prednisolone Acetate 1% and Timolol Maleate 0.5% ophthalmic drops were stored securely; 2. Ensure medication and topical treatments were securely stored and not left at the bedside on 1 out of 5 units in the facility; and3. Ensure that medications in the refrigerator were stored under the proper temperature for 1 out of 3 medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#33), out of a total sample of 29 residents, was treated with respect and dignity. Specifically, the facility failed for Resident #33, to ensure a Foley catheter (tube inserted into the bladder to drain urine) drainage bag was consistently covered with a privacy bag.

Inspectors wroteBased on record review and interview, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations and reporting of allegations and investigative findings for one Resident (#18), out of a total sample of 29 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of potential abuse was reported by the surveyor during the survey.

Inspectors wroteBased on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#18), out of a total sample of 29 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff thoroughly investigated an allegation of abuse for one Resident (#18), out of a total sample of 29 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented care and services consistent with professional standards of practice for four Residents (#12, #1, #145, and #5), out of 29 sampled residents. Specifically, the facility failed:1. For Resident #12, to administer an antihypertensive medication as ordered on days the Resident left the facility to go to dialysis;2. For Resident #1, to monitor that Certified Nursing Assistants (CNA) were not working out of their scope of practice by adjusting liter flow on oxygen tanks;3. For Resident #145, to administer Ativan according to physician's orders; and4. For Resident #5, to ensure a physician's order was in place for self-administration of Muscle Rub (topical analgesic treatment).

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of one nurses observed during a medication pass made two errors out of 32 opportunities, resulting in a medication error rate of 6.25%. Those errors impacted two Residents (#50 and #56), out of three residents observed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food and beverage products as well as maintain safe and clean equipment in three of four nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for two Residents (#13, #33), out of a total of five residents. Specifically, the facility failed:1. For Resident #13, to ensure his/her indwelling Foley catheter (tube inserted into the bladder to drain urine into a collection bag outside of the body) drainage bag was maintained in a sanitary manner through implementation of infection control practices for resident care; and2. For Resident #33, to ensure his/her indwelling Foley catheter drainage bag was maintained in a sanitary manner. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure residents and/or staff properly disposed of cigarette butts in designated smoking receptacles.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment for six Residents (#82, #93, #96, #59, #104, #54) on the [NAME] Unit. Specifically, the facility failed to provide the Residents with assistive devices (wheelchairs and walkers) that were maintained in a clean and comfortable manner and promptly addressed any repair needs as required.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for one Resident (#79), out of 28 sampled residents. Specifically, the facility failed to ensure wound care treatments for Resident #79 were reflective of recommendations from the wound consultant physician and in line with the primary physician's treatment plan.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#91), in a total sample of 28 residents. Specifically, the facility failed to administer oxygen at the correct liter flow per physician's orders, failed to ensure oxygen equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection, and failed to ensure the Resident was referred to a pulmonologist.

Inspectors wroteBased on record review and interview, the facility failed to ensure three Residents' (#1, #123, and #87) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure a gradual dose reduction (GDR) of the antipsychotic medications risperidone and chlorpromazine were attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; 2. For Resident #123, to ensure a GDR of the antipsychotic medication olanzapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; and 3. For Resident #87, to ensure a GDR of psychotropic medication was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain accurate medical records in accordance with professional standards and practices for four Residents (#58, #92, #79, and #90), out of 28 sampled residents. Specifically, the facility failed for Residents #58, #92, #79, and #90 to ensure that documentation of wound physician visits was part of the medical record in a timely manner.

Inspectors wroteBased on record review and interview, the facility failed to have a consistent medical order honoring Advanced Directives for two Residents (#1 and #123), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the physician's order and medical record for Advance Directives matched the court ordered directives; and 2. For Resident #123, to ensure the physician's order and medical record reflected the resident's executed Advance Directives.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident's physician about changes in condition so as to re-evaluate the potential need to alter the treatment plan for one Resident (#90), from a total sample of 28 residents. Specifically, the facility failed to notify the primary physician of a new pressure ulcer in order to alter the treatment plan to prevent deterioration.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#91) with a diagnosed mental condition, out of a total sample of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#91), out of 28 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address Resident #91's BiPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation therapy that delivers air through a face mask to help with breathing) machine use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart) was provided in accordance with professional standards of practice for one Resident (#92), out of a total sample of 28 residents. Specifically, the facility failed to ensure physician's orders were obtained and implemented for the care and maintenance of the Resident's PICC line.

Inspectors wroteBased on observations, interviews, and record reviews, for one Resident (#92) of 28 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary drugs and was not used for an excessive duration. Specifically, the facility failed to ensure the Resident's Fosfomycin (an antibiotic) was administered for only one weekly dose instead of daily, resulting in an additional three administrations of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, for Resident #53, the facility failed to ensure that a bottle of Fluticasone nasal spray (a medication used to treat allergy symptoms), a Trelegy inhaler (a medication used to treat symptoms of lung disease, such as shortness of breath and wheezing), a bottle of Calcium Carbonate chewable tablets (a medication used to treat indigestion), and a tube of Diclofenac cream (a topical medication used to treat pain) were not left unsecured in the Resident's room.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated he/she required physical assistance of two staff members with toileting, personal hygiene, dressing, bathing and turning side to side in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 09/26/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 in bed without another staff member present to assist her, when she turned Resident #1 on his/her side in bed, Resident #1 fell out of bed and landed on the floor on his/her left side. On 10/01/23, Resident #1 was noted with bruising to his/her left shoulder, and his/her left ankle was noted to be bruised and swollen. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing at risk for falls, whose Plan of Care indicated he/she required physical assistance of two staff members with toileting, personal hygiene, dressing, bathing and turning side to side in bed, the Facility failed to ensure he/she was provided with the required level of staff assistance during care to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 09/26/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 in bed without another staff member present to assist her, when she turned Resident #1 on his/her side in bed, Resident #1 fell out of bed and landed on the floor on his/her left side. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, for three Residents (#18, #78, and #97), of 27 sampled residents, the facility failed to ensure quality care was provided. Specifically, 1. For Resident #18, the facility failed to monitor, document, and assess the impaired skin on his/her left lateral ankle, resulting in cellulitis (a serious bacterial infection of the skin); 2. For Resident #78, facility staff moved the Resident with a broken hip off the floor and into a wheelchair prior to the arrival of emergency services; and 3. For Resident #97, the facility failed to follow physician's orders for wound treatments.

Inspectors wroteBased on interviews and policy review, the facility failed to ensure sufficient support staff were available to carry out food and nutrition services to provide a dignified dining experience and maintain clean and well stocked nourishment kitchenettes. Specifically, the facility failed to: 1. Ensure all meals provided to residents were served on dishware, not Styrofoam; and 2. Ensure 4 of 4 nourishment kitchenettes were adequately cleaned and stocked daily, per facility policy.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food is labeled, dated, and stored according to facility policy, and ensure adequate sanitation of equipment in the main kitchen, and 4 of 4 nourishment kitchenettes; and 2. Ensure dish washer temperatures were adequate to wash and sanitize all dishware; and 3. Provide a thermometer or device (T-stick) to ensure the foods brought from home were reheated to an internal temperature of 165 degrees Fahrenheit (F), to prevent potential foodborne illnesses.

Inspectors wroteBased on interview, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program. Specifically, the facility failed to: 1. Follow COVID-19 testing guidance during a COVID-19 outbreak for staff; 2. Ensure glucose monitoring equipment was cleaned per written policies and procedures to prevent the potential spread of infection; 3. Ensure two staff members appropriately wore their surgical masks covering their nose; and 4. Ensure the removal of resident's personal items and terminally clean the room, before a new resident was admitted to the room to prevent the potential spread of infection.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a care plan was developed and implemented for four Residents (#70, #87, #106, and #18), out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #70, implement his/her activities of daily living (ADL) care plan of utilizing two staff members during care; 2. For Resident #87, develop a care plan for cardiac conditions and the use of high risk medications; 3. For Resident #106: a. develop a care plan for a pressure ulcer and for the use of antibiotics, and b. implement his/her alteration in skin integrity care plans; and 4. For Resident #18, develop a care plan for impaired skin integrity of the left lateral ankle.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to maintain professional standards in managing and caring for urinary catheter devices for two Residents (#70 and #15), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #70, to ensure that catheter care and flushes were provided per physician's orders to prevent blockage; and 2. For Resident #15, to ensure that catheter care and monitoring of bedside drainage was performed every shift to prevent catheter complications.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure its staff provided respiratory care consistent with professional standards of practice and the comprehensive care plan for two Residents (#70 and #62), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #70, to ensure tracheostomy (trach- an opening created in the windpipe to allow air and oxygen to reach the lungs) care and respiratory evaluations were done per physician's orders and to maintain and monitor the Resident's trach and equipment; and 2. For Resident #62, to ensure Oxygen was administered according to physician's orders.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the nursing staff completed training as outlined in the Facility Assessment tool. Specifically, the facility failed to provide documentation that all training was completed for 3 out of 5 staff training records reviewed. In addition, the facility could not verify all licensed nursing staff currently working completed all their competencies and Certified Nursing Assistant (CNA) training was a minimum of 12 hours.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required no less than 12 hours of annual training, which at a minimum must include dementia and abuse training for 1 of 2 CNA education files reviewed. In addition, the facility could not provide documentation to show CNAs working in the building completed at least 12 hours of annual in-service training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discussion regarding advance directives occurred for one sampled Resident (#46), in a total sample of 27 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a physician was notified of recommended medication changes for one Resident (#78) in order to alter the treatment, in a total sample of 27 residents. Specifically, the facility failed to notify the physician in a timely manner of recommendations from Hospice to increase pain medications and decrease psychotropic medications.

Inspectors wroteBased on observation and interview, the facility failed to maintain the bathroom in a clean, comfortable, working order for one Resident (#63), out of a sample of 27 residents.

Inspectors wroteBased on record review, policy review, observation, and interview, the facility failed to implement the physician's orders for an air mattress and accurately document its use for one Resident (#105) with a history of pressure ulcers, out of a total sample of 27 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed for one Resident (#70), out of a total sample of 27 residents, to ensure staff provided adequate supervision and assistance to prevent two falls.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#105) with a history of trauma, out of a total sample of 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs, without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for one Resident (#87), out of a total sample of 27 residents. Specifically, the facility failed to monitor for adverse side effects of an anticoagulant (blood thinning medication to prevent clots), including signs/symptoms of bruising, bleeding, and deep vein thrombosis (DVT-blood clot).

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic medications without adequate monitoring for behaviors to ensure the safe administration of medications for one Resident (#87) out of a total sample of 27 residents. Specifically, the facility failed to ensure for Resident #87, resident specific, targeted behaviors were identified and monitored for the use of Xanax (used to treat anxiety), Buspar (used to treat anxiety), Zoloft (used to treat depression and anxiety) and Trazodone (used to treat depression).

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and only authorized personnel were permitted access.

Inspectors wroteBased on observations, interviews, policy review, and records reviewed for one Resident (#18) of 27 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #18, the facility failed to initiate replacement of lost/missing dentures.

Inspectors wroteBased on policy review, interview, and records reviewed for three Residents (#18, #116, and #12), of 27 sampled residents, the facility failed to ensure written notice for transfer or discharge was provided to the Residents and/or Resident Representatives before transferring to the hospital.

Inspectors wroteBased on policy review, interview, and records reviewed for three Residents (#18, #116, and #12), of 27 sampled residents, the facility failed to ensure written notification of the bed hold policy was provided to Residents and/or Resident Representatives prior to hospital transfers.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the Resident's status for 1 out of 2 closed records reviewed and for one Resident (#70), out of a sample of 27 residents. Specifically, the facility failed: 1. For Resident #137, to ensure accuracy when coding discharge status; and 2. For Resident #70, to ensure accuracy when coding falls.