Plymouth Rehabilitation & Health Care Center

In the surveyor’s words

From the most serious findings on record at Plymouth Rehabilitation & Health Care Center, in the surveyor’s own words.

• Actual harm, widespreadF725Nov 16, 2021

  Based on observation, interview, and schedule review, the facility 1) Failed to maintain sufficient staffing to monitor the oral intake and weights for three Residents (#50, #66, #93) resulting in weight loss; 2) Failed to ensure there was clinical staff present to assure resident safety for one Resident (#128); 3) Failed to ensure there was sufficient staff available to provide nursing services and the adequate care required to meet the residents' needs and; 4) Failed to maintain sufficient staff to provide assistance with feeding and timely meal service, out of a total sample of 30 residents. […]

• Actual harm, patternF692Nov 16, 2021

  Based on observations, interviews, record reviews, and policy review, the facility failed to ensure five Residents (#50, #66, #93, #29 and #110) maintained their nutritional status, out of a total sample of 30 residents. Specifically, 1. For Resident #50, the facility failed to ensure the resident received A.) adequate nutrition through food by mouth; B.) tube feeding as ordered; and C.) house supplement as ordered to maintain nutritional status; 2. For Resident #66, the facility failed to ensure a bolus feed and water were administered as ordered and weights were obtained weekly to ensure monitoring of any changes; 3. For Resident #93, the facility failed to ensure tube feedings were administered as ordered and weights were obtained weekly to monitor for changes, as ordered; 4. […]

• Actual harm, isolatedF689Jul 21, 2026

  Based 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… […]

• Actual harm, isolatedF656Oct 25, 2023

  Based 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. […]

• Actual harm, isolatedF689Oct 25, 2023

  Based 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. […]