Plymouth Place

In the surveyor’s words

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

• Actual harm, isolatedF600Jan 2, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when the facility failed to have R1's non-healing, chronic wounds assessed by a physician. This failure resulted in R1 being admitted to the hospital within 25 hours of discharge from the facility with a diagnosis of gangrene of the left first, second, and third toes, and requiring a left, above the knee leg amputation. This applies to 1 of 1 resident (R1) reviewed for wound care in the sample of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 transferred to a different nursing facility on December 10, 2024. […]

• Actual harm, isolatedF684Jan 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident's non-healing, chronic wounds were assessed by a physician, failed to do a wound assessment prior to a resident's discharge from the facility, and failed to provide wound treatments as ordered by the physician. This failure resulted in R1 being admitted to the hospital within 25 hours of discharge from the facility with a diagnosis of gangrene of the left first, second, and third toes, and requiring a left, above the knee leg amputation. This applies to 8 of 8 residents (R1, R2, R3, R4, R5, R6, R7, and R8) reviewed for wound care in the sample of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Mar 30, 2023

  Based on observation, interview and record review, the facility failed to ensure safety while transporting a resident in a wheelchair. R18 was transported by staff without legs rests attached to the wheelchair and fell forward when R18 placed her feet down. This resulted in R18 requiring sutures and an emergency room visit. The facility also failed to ensure proper techniques were utilized for R15 and R49 during transfers. This applies to 3 of 4 residents (R15, R18, R49) reviewed for falls and supervision in the sample of 20. The findings include: 1. […]

• Actual harm, isolatedF689Jul 19, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident's shower area was free from accident hazards. This failure resulted in R1 falling from a shower chair and sustaining three rib fractures. This applies to 2 of 3 residents (R1, R2) reviewed for accidents and injury in the sample of 3. The findings include: On July 14, 2022 at 2:25 PM, V2 (Director of Nursing/DON) said on July 5, 2022, R1 and R2 sustained falls in the same shower room at the facility. V2 identified the resident shower area where R1 and R2 sustained falls and identified the shower chair used during R1 and R2's shower. The shower area and shower chairs were inspected with V2. No defects or damaged parts were noted on the shower chairs. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2025

  Based on observation, interview and record review, the facility failed to maintain the kitchen in a manner to prevent foodborne illness. This applies to 77 residents in the facility receiving dietary services. Findings include: On 01/21/25 at 03:53 PM, V1 (Administrator) confirmed 77 residents were being served from dietary services on entry to the facility 01/21/25. On 01/21/25 at 09:57 AM, the kitchen tour began in the lower-level kitchen with V3 (Culinary Director) and V12 (Chef). V3 stated the kitchen serves the entire facility. 1. […]