Plymouth Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, monitor, and provide timely medical interventions for a resident with cloudy urine, thick sediments and an indwelling catheter.This applies to 1 of 1 resident (R10) reviewed for urinary tract infection (UTI) and catheter care in the sample of 18. The findings include:R10 was admitted to the facility on [DATE]. R10's face sheet showed multiple diagnoses including pressure ulcer of the right ankle, pressure induced deep tissue damage of right heel, major depressive disorder, hearing loss, fatigue, neuromuscular dysfunction of the bladder, muscle wasting and atrophy, protein calorie malnutrition, and chronic respiratory failure. R10's active physicians' orders showed R10 has an external urinary catheter for neurogenic bladder and an order for catheter care to be provided every shift. R10's active care plan dated December 16, 2025, showed R10 has a size 16 French catheter in place. R10 is at risk for infection related to the presence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to document pain assessment, failed to document in the eMAR (electronic Medical Administration Record) the opioid medication that was administered, and failed to monitor and document for the effectiveness and/or adverse effects of the administered opioid medication to ensure that a resident's pain was managed.This applies to 1 of 4 residents (R87) reviewed for pain management in the sample of 18.The findings include:R87 was admitted to the facility on [DATE] with multiple diagnoses including aftercare following joint replacement surgery and presence of right artificial knee joint, based on the face sheet.R87's admission MDS (minimum data set) dated February 13, 2026 showed that the resident was cognitively intact. The same MDS showed that the resident was identified with occasional pain with pain intensity of 5 and receives scheduled pain medication and PRN (as needed) pain medication.On February 23, 2026 at 11:00 AM, R87 was sitting in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to perform hand hygiene and gloving during eye medication administration and blood glucose monitoring. The facility also failed to implement enhanced barrier precautions and use personal protective equipment during wound care. This failure applies to 3 of 3 residents (R10, R68, and R88) reviewed for infection control in a sample of 18.Findings include: 1. On February 24, 2026 at 10:09 AM, V7 (Registered Nurse/RN) prepared and administered eye drop medications to R10's Right eye. At 10:18 AM after administering eye drops (Atropine 1 % eye drops) V7 performed hand hygiene using alcohol rub/sanitizer and put on a clean pair of gloves. While wearing clean gloves V7 then removed the R10's sweater from behind R10's back and placed the sweater on the back of the resident's wheelchair. V7 then picked up and handled puzzle papers and other items from R10's bedside table. At 10:20 AM without removing used gloves, performing hand hygiene, and putting a clean pair of gloves V7 proceeded to open and administer eye drops…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The dry storage contained: A dented 4lb (pound) 4oz (ounce) can of mushrooms. A dented 6lb 12 0z can of buttered beans. Two dented 6lb 12oz cans of sweet potatoes. A dented 6lb 9 oz can of sliced carrots. The facility policy Receiving Goods and Storage of Goods dated 10/19 states if questionable cans are identified after receival, remove form their storage place and place in the Dented Cans area identified in the Dry Storage. 2. On 01/21/25 at 10:15 AM, the walk-in freezer contained: Items identified by V12 as chicken tenders that had fallen out of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed to self-administer medications and keep them at their bedsides. This applies to 4 of 4 residents (R9, R34, R235, R237) reviewed for medication storage in a sample of 23. The findings include: 1. On 01/21/25 at 11:15 AM a generic pain-relieving cream with unlabeled Lidocaine (Lidocaine Hydrochloride 4%) and unlabeled hemorrhoidal relief cream maximum strength bought from a local pharmacy was observed on R34's nightstand. R34 said family member bought medication for her. She said she rubs the pain-relieving ointment with Lidocaine on her thighs. She said she uses both creams as needed. A review of R34's POS (Physician Order Sheet) showed an order for Preparation H External Cream 1% (Hydrocortisone Rectal), apply to hemorrhoids every six hours as needed after bowel movement. There was no order for pain-relieving cream with Lidocaine, no order for the medications to stay at bedside, and no order for self-administration of medications. 2. On 01/21/25 at 10:24 AM a tube of Ketoprofen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safely transfer, position, and implement fall prevention interventions for residents at risk for falls. This applies to 4 out of 6 residents (R55, R285, R49, R12) reviewed for safety and accidents in a sample of 23. The findings include: 1. On 1/22/2025 at 3:00 PM, V5 (Certified Nurse Assistant/CNA) and V10 (Licensed Practical Nurse/LPN) were assisting R55 in bed. R55 had a bruise on his right wrist and a skin tear on his right knee. V5 said R55 had recently fallen out of bed and possibly sustained those injuries then. The left side of R55's bed was parallel to the wall with approximately 12 inches of space in between. R55's boundary mattress was not secured to the bed's frame. V2 (DON/Director of Nursing) said R55 was dependent on his care and required 2-staff assistance with his bed mobility. On 1/23/2025 at 1:00 PM, V7 (CNA) said that on 1/19/2025, she was providing incontinence care to R55 in bed when he fell out of bed. V7 said she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents' rooms with sharps disposal containers were safely maintained. This applies to 5 residents (R3, R73, R287, R79, and R39) reviewed for facility environment in a sample of 23. The findings include: On 1/21/2025 at 10:15 AM during the initial tour of the facility, five residents' rooms (R3, R73, R287, R79, and R39) were observed with overflowing sharps disposal containers: 1. R3's sharps disposal container located in her room was overfilled above the indicated full line and contained sharp items on top of the security flip lid. 2. R73's sharps disposal container located in her room was overfilled above the indicated full line and contained sharp items on top of the security flip lid. 3. R287's sharps disposal container located in her room was overfilled above the indicated full line and contained sharp items on top of the security flip lid. 4. R79's sharps disposal container located in her room was overfilled above the indicated full line and contained sharp items on top of the security flip…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a warm, comfortable room. This applies to 2 out of 3 residents (R77 and R67) reviewed for homelike environment in a sample of 23. The findings include: On 1/21/2025 at 1:50 PM, R77 and R67 (roommates) were in their room. R77 said he gets extra cold because the room's heater unit has not been working for weeks. On 1/21/2025 at 2:00 PM, V1 (Administrator) was asked to assess the room and said the heating unit in the room had been broken for more than a week and was still waiting to be repaired. V1 said urgent maintenance work orders should be addressed within 24 hours and non-urgent should be completed within 3-7 days. On 1/23/2025 at 8:55 AM, V4 (Director of Facilities and Safety) said he received a Maintenance Work Order request for the room's heating unit on 1/5/2025. V4 said the temperature outside the room in the hallway was checked and noted at 72 F (Fahrenheit) degrees, but the temperature inside the room was not checked on 1/6/2025. V4 said resident rooms were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure resident beds were safely maintained. This applies to 2 out of 3 residents (R55 and R14) reviewed for resident equipment in a sample of 23 1. R14 MDS (Minimum Data Set) dated 1/3/25, shows he is cognitively intact. R14 requires substantial staff assistance with repositioning in bed and is dependent on staff transfers between the bed and chair. R14's current care plan includes an ADL (Activities of Daily Living) self-care deficit related to mobility deficits and weakness. On 01/21/25 at 11:33 AM, R14 was on an airloss mattress with approximately four inches of his bed frame exposed on each side of his bed. On 01/23/25 at 11:59 AM, R14 was still on an air mattress with approximately four inches of his bed frame exposed on each side of his bed. On 01/23/25 at 01:30 PM, V2 DON (Director of Nursing) stated staff that provide direct care are responsible for making sure the bed is safe for the resident. If there is any issue the direct care staff should place a work order to maintenance to have the equipment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 2/13/24 documents that the total census was 68 residents. On 2/14/24 at 11:41 AM, V4 (Dietician) said all 68 residents eat from the facility kitchen. On 2/13/24 from 10:41 AM through 11:40 AM, the facility kitchen was toured in the presence of V5 (Director of Food and Nutrition) and V6 (Executive Chef) and the following was found: In the Dairy Cooler: 1. A large sized opened bag of sliced pepperoni, no label or date. 2. A medium sized opened bag of sliced salami, no label or date. 3. An opened 3.5 pound pre-cooked buffalo chicken breast, not sealed and placed back in cardboard box, with the chicken touching the cardboard box packaging. Dry Storage: 4. Two 6 pound 15 ounce cans of tomato…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.