Plymouth Harborside Healthcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 13, 2026

  Based on observations, records reviewed, and interviews, the facility failed to ensure that adequate supervision and interventions were implemented to prevent accidents and failed to maintain an environment free of accident hazards for four Residents (#80, #15, #82, #84) of a total of 20 residents sampled. Specifically, the facility failed to:1. Ensure adequate supervision for Resident #80, a known elopement risk, and enabled access to a designated smoking area with unlocked doors that had access to outside of the facility, thus placing Resident #80 at Immediate Jeopardy risk for serious harm or death.In addition to the Immediate Jeopardy, non-compliance of this requirement also existed because the facility failed to:2. […]

• Immediate jeopardy, isolatedF678Oct 11, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders indicated he/she was a full code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive), the Facility failed to ensure nursing staff provided life saving measures to him/her, when on [DATE], at approximately 5:30 A.M., after Nurse #1 found Resident #1 unresponsive, without pulse and without respiration, she did not call a Code Blue, per facility policy, and Resident #1 was not administered cardiopulmonary resuscitation (CPR). […]

• Immediate jeopardy, isolatedF726Oct 11, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders indicated he/she was a full code (if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive), the Facility failed to ensure nursing staff were competent and had the necessary skill set to respond in an emergency situation which included adequately assessing a resident who was unresponsive with a significant change in condition, calling a Code Blue, and initiating 911 to activate Emergency Medical Services (EMS). […]

• Actual harm, isolatedF600Sep 16, 2025

  Based on records reviewed and interviews for one of four sampled residents (Resident #2), who was known to exhibit intrusive, combative and aggressive behaviors towards staff, residents, and visitors, the Facility failed to ensure that other residents residing on his/her unit were free from physical abuse, when between May 2025 and August 2025, Resident #2 was involved in several altercations, which included being witnessed by staff as he/she punched a resident in the stomach, climbed into another residents bed and became combative with attempts to be redirected, and it was alleged that he/she punched a resident on the arm and in the face during an unwitnessed altercation. […]

• Actual harm, isolatedF656Aug 5, 2025

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) whose Plan of Care related to Activities of Daily living (ADLs) indicated that he/she required continual supervision (staff member to be with him/her during entire task) with meals, the facility failed to ensure that staff consistently implemented and followed his/her care plan interventions, when on 05/13/25, Resident #1 was served his/her breakfast tray, then left unsupervised in his/her room with his/her meal, he/she spilled a hot beverage on his/her upper legs, and sustained second-degree burns (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the front side of his/her left thigh, which required… […]