Plymouth Village

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical record contained accurate documentation of fall history for one of three residents (Resident 1) reviewed for falls. This failure had the potential to result in an inaccurate assessment of fall risk and inappropriate fall prevention interventions, placing Resident 1 at increased risk for subsequent falls. During a review of Resident 1's clinical record, the admission Record (contains demographic and clinical data), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (memory loss beyond expected age and difficulty with thinking), history of falling, and unspecified fracture (break of the bone) of the lower end of the left radius (lower forearm) and left ulna (broken left wrist). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. The main kitchen floors had accumulation of food crumbs, black stains, and dirt; the walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors had multiple cilantro leaves, cauliflower pieces, and multiple moist black and brown residue under the shelf. 2. Food equipment such as the toaster had black grime, white residue, and food crumbs; the mixer was found with multiple reddish-orange splashes on the handle. 3. The edge of the wall under the three-compartment sink had black build up and multiple white residues. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained when a Laundry Staff used a dirty laundry basket (a basket for holding clothes and linen that have been washed) to transfer washed linens into the dryer machine. This failure had the potential to cause harm to the 44 residents residing within the facility by increasing the risk of exposure and spread of infection (the process by which an infectious agent (like a virus or bacteria) moves from one source to another, causing illness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of seven residents (Residents 4) reviewed for dining observation when a Licensed Vocational Nurse (LVN 2) was standing over Resident 4 while feeding him lunch on June 16, 2025. This failure resulted in staff not maintaining Resident 4's individuality and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and facility policies and procedures for one of three sampled residents (Resident 12) reviewed for respiratory care when Resident 12's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date that it was changed. This failure had the potential for Resident 12 to be at risk of developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were two medication errors identified out of 27 opportunities for errors, affecting one of 13 residents (Resident 14), resulting in an overall medication error rate of 7.4 percent when Resident 14's Levothyroxine (replacement hormone for people whose thyroid gland is not working properly) and Hydrocodone-Acetaminophen (medication used to relieve severe pain) were crushed together during medication administration. These failures had the potential for Resident 14 to have negative health consequences and effectiveness of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the privacy of patient health records for one of six sampled residents (Resident 14) was maintained when a Licensed Vocation Nurse (LVN 3) left Resident 14's health information on the computer screen, unattended in the hallway, visible for anyone to see. This failure had the potential for Resident 14's private information to be disclosed without authorization which could lead to Health Insurance Portability and Accountability Act (to protect medical records and other personal information) violations.

Inspectors wroteBased on interview and record review, the facility failed to implement a process to routinely evaluate contracted nursing staff on their skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) for 10 of 10 contracted staff (one Licensed Vocational Nurse [LVN 1], and nine Certified Nursing Assistants [CNA 1, 2, 3, 4, 5, 6, 7, 8 and 9]). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance, when four bags of raw chicken had freezer burn (frozen foods are exposed to cold, dry air, which causes them to dehydrate as the outer layers lose moisture. One of the most commonly recognized signs of freezer burn is the formation of ice crystals on the outside of food, making it appear frost bitten). This had the potential for the chicken to not be palatable when cooked and served to 40 of 41 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary kitchen when: 1. Floors under equipment in multiple areas of the kitchen had a build up of black grime, old food, crumbs, and trash, this had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 2. Two convection (fans to circulate air around food to create an evenly heated environment) ovens, two ranges, a grill top, a food warmer box (appliance that holds already cooked foods at ideal temperatures until they are ready to be served) and 4 waffle irons, had a buildup of black grime, and yellow crusted grime. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers enteral feeding formula and hydration directly to the stomach) was implemented for one of two sampled residents with G-tube (Resident 37), when: 1) The G-tube pump (a machine which helps to deliver the enteral formula to the resident), was off and 1500 cc (cc - unit of volume) of Glucerna (enteral feeding formula) 1.2 cal [calories] was left in the bottle. This failure resulted in Resident 37 not receiving the calculated amount of enteral feeding formula for the day, as per physician's orders. 2) The order for Glucerna 1.2 cal was not transcribed (written) accurately onto the physician's orders (It was ordered via oral route of administration on April 1, 2024, instead of via G-tube). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Front Hall medication cart), with seven missing signatures for narcotics count. This failure had the potential for drug diversion (Illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for one of one resident (Resident 247) when a bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing morphine (medication used to treat pain) had no expiration date ( a date that indicates when medicine is no longer effective) written in the label. This failure had the potential to result in staff administering an expired medication to Resident 247 which can alter the efficacy (ability to produce desired effects) of the medications and reduce its therapeutic effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary and safe medication storage in one of two medication carts (a cart used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) when the hearing aids (a small device that fits in or on the ear, worn by a partially deaf person to amplify sound) for four of four residents (Resident 39, 29, 13 and 25) were found inside a medication cart's narcotic drawer. This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and jeopardize the health and safety of (Resident 39, 29, 13 and 25).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary kitchen environment when: 1) The two ice machines that provide ice for 37 of 38 residents of the facility, were not clean to sight and touch. Ice machine 1 had a yellowish build-up in the ice chute (where ice is dispensed and travels from the ice maker to enter the ice bin). Ice machine 2 had a brownish build-up. This had the potential to contaminate the ice and cause foodborne illness. 2) The walk-in freezer that provides storage of food for 37 of 38 residents had liquid food spills, food crumbs and trash on the floor. This had the potential for microorganism growth and to attract pests. 3) The cabinet below the steam table (appliance that keeps food warm after it's been prepared and cooked) in the dining room that services meals for 37 of 38 residents had food crumbs and a rusty liquid spill. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 17) was provided reasonable accommodation of needs, when Resident 17's hearing deficit was not addressed by the facility. This failure resulted in Resident 17 not receiving an adequate hearing assessment and Resident 17 potentially failing to achieve her highest level of functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 28) was provided a safe, clean, comfortable, and homelike environment when Resident 28's wheelchair was not found in good repair. This failure had the potential to result in discomfort for Resident 28, which could have negatively impacted the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess a resident with a hearing deficit when one of three sampled residents (Resident 17), Minimum Data Set (MDS -a federally mandated assessment for residents in nursing homes) who was known by the staff to have a hearing deficit. This failure had the potential to cause Resident 17 to receive inadequate care at the facility and adversely affect Resident 17's quality of life and ability to function since the time of admission.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of four sampled residents (Resident 9 and Resident 28) receiving anticoagulant (blood thinner) medication. This failure had the potential to cause adverse health outcomes such as bleeding and hemorrhage (profuse discharge of blood from a ruptured blood vessel) which may lead to hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) care for one of three sampled residents (Resident 28), when Resident 28 was instructed to hold his catheter during a urinary catheter irrigation (a sterile procedure to flush the urinary catheter to keep it clear and working properly) procedure. This failure had the potential to result in a urinary tract infection (UTI - an infection in any part of the urinary system) due to improper handling of the urinary catheter, which could have caused the resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate administration of prescribed drugs and biologicals, when a medication was not administered as ordered by the physician for one of seven sampled residents (Resident 17). This failure resulted in Resident 17 receiving a doubled dosage of an ordered laxative medication which resulted in a medication error and had the potential to cause adverse drug effects to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection prevention and control measures for two of two sampled residents (residents 28 and 30) when: 1. Resident 28's wheelchair was ripped. 2. Resident 30's toothbrush and hair comb were found in a shared bathroom sink, unlabeled. These failed practices had the potential for the spread of infection and placing residents' health and safety at risk of a highly susceptible population of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for all residents in the facility, when an open gap on the dining room floor was present. This failure had the potential to impose a tripping hazard for the residents and could have contributed to resident falls with injuries.