Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plymouth Village during CMS and state inspections, most recent first.
Inaccurate fall history documentation was found for a resident with dementia, a history of falls, and a left wrist fracture. The chart showed a fall and a fall risk assessment indicating multiple recent falls, but a later fall risk evaluation incorrectly stated there were no falls in the past 3 months despite another documented fall. The DON verified the documentation was not accurate and stated the facility’s falls and charting policies were not followed.
Surveyors found that kitchen floors, food storage areas, and equipment were not properly cleaned, with accumulations of food debris, stains, and residue present. Staff interviews and record reviews confirmed that cleaning procedures and policies were not followed, creating unsanitary conditions for 44 residents receiving food from the kitchen.
Laundry staff used a visibly dirty laundry basket, containing trash and soiled items, to transfer washed linens from the washing machine to the dryer. This action was not in accordance with facility policy, which requires linen carts to be cleaned and disinfected and clean linen to be protected during transport. Staff interviews confirmed the expectation for clean baskets and revealed inconsistencies in cleaning practices.
A nurse was observed standing over a resident with hemiplegia and dysphagia while feeding, contrary to facility policy requiring staff to be seated and attentive to resident dignity during meals. Both the nurse and DON confirmed that this practice did not align with expectations for maintaining resident comfort and dignity.
A resident with COPD and other cardiac conditions did not have their oxygen tubing labeled with the date of last change, contrary to physician orders and facility policy requiring weekly changes. Staff were unable to confirm when the tubing was last replaced, and the DON acknowledged the policy was not followed.
A medication error rate above 5% was identified when a nurse crushed and combined Levothyroxine and Hydrocodone-Acetaminophen together for a resident, contrary to physician orders requiring separate preparation. The DON confirmed the facility did not follow its medication administration policy.
A LVN left a resident's electronic health record open and unattended on a computer in the hallway while administering medication, making the resident's private health information visible to others. The DON confirmed this action was not in accordance with the facility's HIPAA Privacy Policy, which requires safeguards to protect patient information.
The facility failed to implement a process to routinely evaluate the competencies of contracted nursing staff, including one LVN and nine CNAs. The DON and DSD were unable to provide documented competency checklists, and the facility lacked a policy for validating contracted staff skills. Interviews revealed that staff were oriented to basic operations but did not receive competency checklists.
The facility failed to store food properly, resulting in four bags of raw chicken with freezer burn in the walk-in freezer. This issue, observed and confirmed by the Food Service Director, could affect the palatability of food served to 40 of 41 medically compromised residents. The facility's policy mandates proper storage to prevent contamination and maintain food safety.
The facility failed to maintain a sanitary kitchen environment, with grime and food buildup under equipment and on kitchen appliances, and unclean buckets used as funnels. The Executive Chef and Food Service Director acknowledged the need for improved cleaning practices.
A resident with hemiplegia, aphasia, and dysphagia did not receive the correct amount of enteral feeding formula due to the G-tube pump being turned off early and an incorrect transcription of the physician's order. The facility's policies on enteral nutrition and tube feeding were not followed.
The facility failed to maintain accurate records of controlled medications for one medication cart, with seven missing signatures for narcotics count on various dates. The DON acknowledged the issue, and an LVN admitted to forgetting to sign the log, despite the facility's policy requiring both incoming and outgoing nurses to count and sign the sheet at each shift change.
The facility failed to ensure drugs were labeled correctly when a bubble pack containing morphine for a resident had no expiration date. The DON and pharmacy consultant confirmed the oversight, which could lead to administering expired medication.
The facility failed to maintain sanitary medication storage when hearing aids for four residents were found in a medication cart's narcotic drawer. The DON and IP confirmed there was no policy for this practice, leading to potential cross-contamination and infection risks.
Inaccurate Fall History Documentation
Penalty
Summary
The facility failed to ensure the clinical record contained accurate documentation of fall history for one resident reviewed for falls. The resident was admitted with diagnoses including unspecified dementia, history of falling, and an unspecified fracture of the lower end of the left radius and left ulna. The record included a Change in Condition Note showing the resident sustained a fall on April 4, 2026, and a Fall Risk Evaluation dated April 4, 2026 that indicated the resident had 3 or more falls in the past 3 months. A subsequent Fall Risk Evaluation dated May 6, 2026 documented that the resident had no falls in the past 3 months, despite the documented fall on April 4, 2026 and another fall on May 6, 2026. During observation on May 18, 2026, the resident was sitting upright in bed with the bed in the lowest position, had a cast on the left upper extremity, and was wearing a fall bracelet. The DON reviewed the records and verified that the April 4, 2026 fall occurred but was not accurately documented on the later Fall Risk Evaluation. The DON also reviewed the facility's Falls-Clinical Protocol and Charting and Documentation policies and stated both were not followed.
Failure to Maintain Sanitary Food Preparation and Storage Areas
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding safe and sanitary food preparation and storage practices. The main kitchen floors were found with accumulations of food crumbs, black stains, and dirt. The walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors contained cilantro leaves, cauliflower pieces, and moist black and brown residue under the shelf. Food equipment, such as the toaster, had black grime, white residue, and food crumbs, while the mixer had reddish-orange splashes on the handle. Additionally, the edge of the wall under the three-compartment sink had black buildup and multiple white residues. Staff interviews confirmed that these areas and equipment were expected to be cleaned daily or after each shift, but these procedures were not followed. Record reviews showed that the facility had written policies and cleaning checklists detailing daily and weekly cleaning requirements for all kitchen areas and equipment. The Director of Dining Services acknowledged that these policies and checklists were not adhered to. The FDA Federal Food Code was referenced, indicating that nonfood-contact surfaces must be kept free of dust, dirt, food residue, and other debris to prevent the accumulation of pathogenic microorganisms and attraction of pests. These deficiencies had the potential to cause foodborne illnesses among the 44 residents who received food from the kitchen.
Improper Use of Dirty Laundry Basket for Clean Linens
Penalty
Summary
A deficiency was identified when laundry staff used a dirty laundry basket to transfer washed linens from the washing machine to the dryer. During an observation in the laundry room, a large blue plastic laundry basket with a lid covered by a stained white sheet was found near the dryer. Upon removal of the sheet, the lid and the inside of the basket were observed to be dirty and contained various items, including trash bags, dirty socks, a coffee creamer packet, a dirty mop, a blue blanket, dirty tissue papers, and a spray bottle. The laundry staff stated that the basket was used for transferring clean linens and that the sheet covering it was changed weekly, despite the laundry supervisor stating it was changed daily. The Infection Preventionist and Director of Nursing both acknowledged that the basket should not have been used in this condition and that staff had been educated on proper linen handling and transport. A review of the facility's policy and procedures indicated that linen carts are to be cleaned and disinfected whenever visibly soiled and according to an established schedule, and that clean linen must be protected from dust and soiling during transport and storage. The Director of Buildings and Grounds confirmed the expectation that only clean laundry baskets should be used. The use of a visibly dirty basket for transporting clean linens was not in accordance with facility policy and procedures, as confirmed by staff interviews and record review.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed standing over a resident while feeding him lunch, rather than being seated as required by facility policy. The resident involved had a history of hemiplegia affecting the right dominant side, dysphasia, and dysphagia, necessitating assistance with eating. The facility's policy on meal assistance specifies that staff should not stand over residents while feeding them, emphasizing the importance of maintaining safety, comfort, and dignity. During interviews, both the LVN and the Director of Nursing confirmed that staff are expected to be seated and engaging with residents during meals. This incident demonstrated a failure to uphold the resident's dignity and individuality during mealtime assistance.
Failure to Label and Change Oxygen Tubing per Policy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), diastolic heart failure, and atrial fibrillation was not provided safe and appropriate respiratory care as required by physician orders and facility policy. The resident had a physician order for oxygen tubing and humidifier changes every Wednesday night shift and continuous oxygen at 2 LPM to maintain oxygen saturation above 90%. During an observation, it was found that the oxygen tubing in use for the resident was not labeled with the date it was last changed, and the Director of Staff Development was unable to confirm when the tubing had last been replaced. Further review of the facility's policy on infection prevention for respiratory therapy revealed that oxygen cannulas and tubing should be changed every seven days or as needed. The Director of Nursing acknowledged that this policy was not followed in the resident's case, as the tubing was not labeled and its change date was unknown. This failure to follow established procedures for respiratory care and infection prevention constituted the deficiency.
Medication Error Rate Exceeds Threshold Due to Improper Crushing and Mixing of Medications
Penalty
Summary
A medication error rate of 7.4 percent was identified during a survey, exceeding the required threshold of less than five percent. Specifically, two medication errors were found out of 27 opportunities, involving one resident who had diagnoses including gastroesophageal reflux, hypothyroidism, and thoracic spine pain. The errors occurred when a nurse crushed and combined Levothyroxine and Hydrocodone-Acetaminophen together for administration, despite physician orders specifying that each medication must be prepared individually if more than one is to be administered. Observation of the medication administration process revealed that the nurse placed both medications in a single pouch, crushed them together, mixed them with applesauce, and administered the mixture to the resident. The nurse stated that mixing medications was acceptable if there was an order, but review of the facility's policy and the physician's orders confirmed that medications should be prepared separately. The Director of Nursing acknowledged that the facility did not follow its own policy regarding medication administration.
Failure to Safeguard Resident Health Information
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to maintain the privacy of a resident's health information by leaving the resident's electronic health record open and unattended on a computer screen in the hallway. The LVN had logged into the resident's record at the medication cart in front of the resident's room and then entered the room to administer medication, leaving the computer screen visible and accessible to anyone passing by. The LVN acknowledged realizing the error only after entering the resident's room and stated awareness that leaving the information unattended was not permitted. The resident involved had been admitted with diagnoses including gastroesophageal reflux, hypothyroidism, and thoracic spine pain. Review of the facility's HIPAA Privacy Policy confirmed that administrative, technical, and physical safeguards were required to protect patient health information from unauthorized disclosure. The Director of Nursing confirmed that the facility's policy was not followed in this instance.
Failure to Validate Competencies of Contracted Nursing Staff
Penalty
Summary
The facility failed to implement a process to routinely evaluate the competencies of contracted nursing staff, including one Licensed Vocational Nurse (LVN) and nine Certified Nursing Assistants (CNAs). During interviews and record reviews, it was found that the facility did not have documented evidence of competency validation for any of the contracted staff currently working at the facility. The Director of Nursing (DON) and the Director of Staffing Development (DSD) were unable to provide documented competency checklists for the contracted staff, and the facility relied on a buddy system for skill validation without proper documentation. The report also highlighted that the facility did not have a policy and procedure in place to validate the competencies and skills of contracted nursing staff. Interviews with the contracted staff revealed that they were oriented to basic facility operations but did not receive or recall any competency checklists during their orientation. The lack of documented competency validation and absence of a formal policy had the potential to compromise the quality of care provided to the residents.
Improper Food Storage Leading to Freezer Burn
Penalty
Summary
The facility failed to store food by methods that conserve nutritive value, flavor, and appearance, as evidenced by four bags of raw chicken with freezer burn observed in the walk-in freezer. Freezer burn, characterized by ice build-up and air expansion in the bags, can lead to food dehydration and loss of moisture, making the chicken potentially unpalatable when cooked and served. This issue was identified during an observation on April 22, 2024, and confirmed during an interview with the Food Service Director on April 24, 2024. The facility's policy on food storage, dated January 2023, mandates that all food items be stored to prevent contamination and maintain safety and wholesomeness for human consumption. This deficiency had the potential to affect 40 of 41 medically compromised residents who received food from the kitchen.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed by surveyors. Floors under equipment in multiple areas of the kitchen had a buildup of black grime, old food, crumbs, and trash, which could lead to microorganism growth and attract pests. Specific areas noted included under the stainless-steel countertop, behind and under the industrial mixer, and in the dry storage area, walk-in refrigerator, walk-in freezer, and mop closet. The Executive Chef and Food Service Director acknowledged that these areas should be kept clean and added to their cleaning list. Additionally, several pieces of kitchen equipment, including two convection ovens, two ranges, a grill top, a food warmer box, and four waffle irons, had a buildup of black grime and yellow crusted grime. This buildup could lead to microorganism growth and attract pests. The Food Service Director confirmed that the equipment should be kept clean and added to their deep cleaning list. Lastly, two buckets used as funnels to drain cooking liquid from a large steam kettle were found to be crusted with old food. This could lead to microorganism growth and attract pests. The Food Service Director acknowledged that the buckets should be kept clean and free of food residue. The facility's policy and the FDA Federal Food Code were reviewed, both of which emphasize the importance of keeping nonfood-contact surfaces clean to prevent microorganism growth and pest attraction.
Failure to Properly Manage G-Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube) for a resident with hemiplegia, aphasia, and dysphagia. The G-tube pump was found turned off with 1500 cc of Glucerna 1.2 cal remaining in the bottle, resulting in the resident not receiving the calculated amount of enteral feeding formula as per the physician's orders. The Licensed Vocational Nurse (LVN) admitted to turning off the pump earlier than the prescribed time for the resident's morning routine, and the Director of Nursing (DON) confirmed a discrepancy of more than 300 ml of formula that should have been infused by that time. The facility's policy on enteral nutrition was not followed, as the required amount of formula was not administered to the resident. Additionally, the physician's order for the enteral feeding formula was incorrectly transcribed as an oral liquid instead of via G-tube. Both the LVN and the DON acknowledged the error upon review of the physician's orders. The facility's policy on enteral tube feeding via continuous pump, which requires checking the enteral nutrition label against the order before administration, was not adhered to, leading to the potential for the resident to receive the formula via the wrong administration route.
Failure to Maintain Accurate Records of Controlled Medications
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of two medication carts, specifically the Front Hall medication cart. During a review of the narcotics shift count verification signature log, it was found that there were seven missing signatures for narcotics count on various dates in March and April 2024. The Director of Nursing (DON) acknowledged the missing signatures and stated that it is expected for licensed nurses to count and sign the sheet at the beginning and end of each shift. However, the logs showed missing signatures from both incoming and outgoing nurses on multiple occasions. An interview with a Licensed Vocational Nurse (LVN) revealed that the nurses are responsible for counting narcotics together and signing the sheet, but the LVN admitted to forgetting to sign the log. The facility's policy and procedure on controlled substances, revised in November 2022, requires nursing staff to count controlled medication inventory at the end of each shift and for both the incoming and outgoing nurses to make the count together and document any discrepancies. Despite this policy, the required signatures were missing, indicating a failure to adhere to the established procedures for controlled substances management.
Failure to Label Medication with Expiration Date
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for one resident when a bubble pack containing morphine had no expiration date written on the label. During an observation and interview with the Director of Nursing (DON), it was found that the bubble pack for Resident 247's morphine sulfate tablets did not have an expiration date. The DON initially stated that medications could be used within one year of the order date, but later admitted that the facility did not have a one-year use policy and would need to check with the pharmacy consultant. The pharmacy consultant confirmed that he was unaware of the missing expiration date on Resident 247's medication and indicated that the standard for pharmacy is to have a label with an expiration date. A review of the facility's policy and procedures indicated that all prescription medications must have a pharmacy label that includes the expiration date. This failure had the potential to result in staff administering an expired medication to Resident 247, which could alter the efficacy of the medication and reduce its therapeutic effectiveness.
Improper Storage of Hearing Aids in Medication Cart
Penalty
Summary
The facility failed to maintain a sanitary and safe medication storage system when hearing aids for four residents were found inside a medication cart's narcotic drawer. During an observation and interview with the Director of Nursing (DON), it was revealed that the narcotic drawer contained two small black cases, one small gray case, and two clear specimen containers, all containing residents' hearing aids. The DON admitted that these were not new hearing aids and that residents gave their hearing aids to the nurse in the evening to keep them locked. When residents asked for their hearing aids, the nurse would take them out of the narcotics drawer and hand them to the residents without using gloves or cleaning them. This practice was confirmed during an observation where a Licensed Vocational Nurse (LVN) handed a hearing aid to a resident without using gloves or cleaning it first. The DON acknowledged that there was no policy in place for storing hearing aids inside the narcotics drawer. Further investigation with the Infection Preventionist (IP) and another LVN confirmed the presence of hearing aids in the narcotic drawer. The IP was unable to provide a policy regarding the storage of residents' hearing aids and confirmed that no such policy existed. This lack of policy and improper storage practice had the potential for cross-contamination and infection, jeopardizing the health and safety of the residents involved.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Care Center Of Redlands | 0.6 mi | ★★★★★ | 2 | 0 |
| Madison Grove Post Acute | 1.8 mi | ★★★★★ | 17 | 0 |
| Redlands Healthcare Center | 1.8 mi | ★★★★★ | 6 | 0 |
| Redlands Comm Hosp D/p Snf | 1.8 mi | ★★★★★ | 8 | 0 |
| Brookside Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
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