Plymouth Harbor Incorporated

In the surveyor’s words

From the most serious findings on record at Plymouth Harbor Incorporated, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF684Mar 27, 2025

  Based on observation, record review and staff interview, the facility failed to provide care and services in accordance with professional standards of practice by failing to administer medications in accordance with the physician's orders for 1 (Resident #22) of 4 residents reviewed for compliance with physician's orders. The findings included: On 3/26/25 at 8:34 a.m., Licensed Practical Nurse (LPN) Staff A was observed preparing to administer medications to Resident #22, including Vitamin D3. LPN Staff A said she needed to clarify the order for the Vitamin D3 before administering it to the resident. […]

• No harm, potential for more than minimal, patternF689Mar 27, 2025

  Based on observation, record review, and interviews, the facility failed to implement care plan interventions to prevent falls and fall related injuries for 1 (Resident #12) with multiple falls of 2 residents reviewed for fall prevention. The findings included: Review of the clinical record for Resident #12 revealed an admitted [DATE]. Diagnoses included Dementia and Pelvic fracture due to multiple falls. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 1/24/25 revealed Resident #12's cognition was severely impaired with a Brief Interview for Mental Status score of 7. The assessment noted the resident was dependent on staff for toileting (Helper does all the effort). Toilet transfer was not attempted due to safety concerns. […]

• No harm, potential for more than minimal, isolatedF600Dec 11, 2025

  Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility's Abuse Prevention Policy effective 8/18/10, last revised December 2022 revealed Policy: 1. Plymouth Harbor will exercise all possible efforts to reduce the risk to residents from harm or mistreatment and to prevent incidents of Abuse, Neglect, Sexual Misconduct or Exploitation. 2. All allegations of abuse, neglect, sexual misconduct or exploitation of a resident will be thoroughly investigated and the resident protected during the course of the investigation. […]

• No harm, potential for more than minimal, isolatedF578Mar 27, 2025

  Based on clinical record review, resident representative and staff interviews, the facility failed to ensure the clinical record accurately reflected the residents' advance directives for 2 (Residents #5 and #8) of 2 residents reviewed for advance directives. The findings included: Review of the facility's Advance Directive Policy (revised [DATE]) revealed prior to or upon admission of a resident, the Social Services Director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. 1. […]

• No harm, potential for more than minimal, isolatedF657Mar 27, 2025

  Based on observation, interview and record review, the facility failed to develop, implement and revise the care plan to meet the needs and preferences of 3 (Residents #5, #8 and #12) of 3 reviewed for care plans. The findings included: 1. Review of Resident #5's clinical record revealed an admitted [DATE]. Diagnoses included cerebral infarction and dementia. Review of the Minimum Data Set (MDS) Assessment with a target date of [DATE] revealed Resident #5's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 06. […]