Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Harbor Incorporated during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and exit-seeking behavior was physically struck in the face by an LPN during an attempt to prevent elopement, as confirmed by surveillance footage and staff interviews. Security staff assisted in restraining the resident, but the intervention involved physical abuse contrary to facility policy.
The facility did not perform the required differential pressure testing of duct smoke detectors, as identified during a review of fire alarm inspection reports. The Maintenance Director confirmed the testing was not done, which is a requirement under NFPA 72. This oversight could lead to smoke detection devices failing to operate properly, endangering building occupants.
The facility did not perform the required triennial testing of its emergency generator, with the last test recorded in September 2021. This oversight was acknowledged by the Maintenance Director and could lead to generator malfunction during a power failure, affecting the entire facility.
A facility failed to administer medications according to physician's orders, resulting in a deficiency. An LPN was observed preparing to give a resident Vitamin D3, noting a discrepancy in dosage. The MAR indicated a 1000 IU daily dose, but 2000 IU was administered. Another LPN confirmed giving the incorrect dose, and the DON was aware of the issue.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to implement care plan interventions. The resident required two staff for toileting assistance, but only one CNA was present, who was unfamiliar with the care plan. Despite updates to the care plan, interventions like floor mats and staff training were not implemented, leading to repeated falls and injuries.
A resident was administered an incorrect dose of Vitamin D3, receiving 2000 IU instead of the prescribed 1000 IU. This error was identified when an LPN noticed the discrepancy while preparing medications. The DON confirmed awareness of the issue and emphasized the importance of following physician's orders.
A resident with severe cognitive impairment and a history of falls was inadequately supervised during toileting, contrary to the care plan requiring two staff members. The CNA assisting the resident was unfamiliar with the facility's care instructions, leading to multiple falls. Despite care plan updates, interventions were not effectively communicated or implemented, contributing to the resident's repeated accidents.
The facility failed to accurately document the advance directives for two residents. In one case, a resident's legal representative's preference for code status was not reflected in the medical record, and the required documentation was missing. In another case, a resident's son, who held power of attorney, was not consulted about the code status, leading to an incorrect full code status being documented. Both instances highlight a lack of proper verification and documentation of residents' advance directives.
The facility failed to update and implement care plans for three residents, leading to inaccuracies in code status and safety measures. A resident's care plan did not reflect the healthcare representative's wishes, while another resident's son was not consulted about code status. Additionally, a resident's care plan lacked necessary safety interventions, and staff were not adequately trained to access care instructions.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of neurocognitive disorder with Lewy bodies was not protected from physical abuse by staff. The resident, who exhibited agitation, restlessness, and exit-seeking behaviors, was involved in an incident where staff attempted to prevent him from leaving the facility. During the event, the resident attempted to bite an LPN, and multiple staff, including security personnel, intervened to redirect and restrain him. Eyewitness statements and surveillance footage revealed that the LPN approached the resident from behind, forcibly removed his hand from a door handle, and struck him in the face with an open hand while holding his arm. Security staff assisted in restraining the resident and returning him to his wheelchair. The video evidence confirmed the physical contact, which was corroborated by staff interviews and witness statements, some of which described the action as a hit to the resident's face. The facility's abuse prevention policy requires all possible efforts to reduce the risk of harm or mistreatment and to prevent incidents of abuse. Despite this, the actions taken by the LPN in response to the resident's behavior resulted in physical abuse, as defined by the facility's policy and federal regulations. The incident was not initially substantiated by the facility's internal investigation, but direct observations and video evidence indicated that the resident was not protected from physical abuse during the intervention.
Failure to Conduct Required Fire Alarm System Testing
Penalty
Summary
The facility failed to conduct the required differential pressure testing of the duct smoke detectors as part of their fire alarm system maintenance. This deficiency was identified during a review of the facility's fire alarm inspection reports, which did not include results for this specific testing. The Maintenance Director confirmed during an interview that the testing had not been performed. This testing is a requirement under NFPA 72 (2010 edition) Table 14.4.2.2-14 (g)(6), which is crucial for ensuring the proper operation of smoke detection devices. The absence of differential pressure testing could result in the smoke detection devices failing to operate as designed in the event of a fire, thereby endangering the occupants of the building. This issue affects all smoke compartments within the facility, highlighting a significant oversight in the facility's fire safety protocols. The failure to comply with NFPA 72 standards indicates a lapse in the facility's adherence to essential fire safety regulations.
Plan Of Correction
1. Corrective Action for Cited Instance: On April 5, 2025, the facility contracted with our life safety vendor to perform differential pressure testing of all duct-type smoke detectors. This testing was completed by a certified technician on April 21, 2025. 2. Systemic Correction: A full audit of our fire alarm inspection program was completed to ensure all NFPA-required elements are included in annual inspection contracts and vendor documentation. The scope of service was updated and reviewed with the contractor on April 15, 2025. 3. Education: The Maintenance Director and backup technician were trained on NFPA 70 and NFPA 72 testing standards on April 7, 2025. 4. Ongoing Monitoring: A quarterly audit of fire alarm system documentation will be conducted by the Environmental Services Manager to ensure compliance. 5. Quality Assurance: Results and findings will be reported to the QA Committee monthly for six months, beginning April 2025, for review and revision recommendations. Completion Date: April 27, 2025
Failure to Conduct Triennial Generator Testing
Penalty
Summary
The facility failed to conduct the required triennial testing of its emergency generator, as evidenced by a review of maintenance and testing records. The last recorded triennial load test was dated September 30, 2021, indicating that the facility did not perform the necessary testing within the stipulated three-year period. This oversight was identified during a record review on April 1, 2025, at 10:30 a.m. The Maintenance Director acknowledged the absence of current triennial load testing records during the review. This deficiency could potentially lead to a malfunction of the generator in the event of a power failure, resulting in a loss of power to the entire facility. The facility's failure to adhere to the NFPA 110 standards for generator maintenance and testing poses a risk to the safety and operational integrity of the facility.
Plan Of Correction
1. **Corrective Action for Cited Instance:** The facility immediately scheduled the required 4-hour triennial load test, which was conducted and completed on May 2nd, 2025, and followed with an amendment signed 04-09-2025 to the current contract for a 4-hour load bank every three years and two-hour load bank to comply ordinance by a licensed contractor in accordance with NFPA 110 Section 8.4.2. 2. **Systemic Correction:** A compliance calendar has been implemented to track future due dates for generator testing, inspections, and maintenance. 3. **Education:** The Maintenance Director received updated training on generator testing frequency requirements per NFPA 110 and NFPA 111 on April 7, 2025. 4. **Ongoing Monitoring:** All generator test logs, and vendor documentation will be reviewed quarterly led by the Director of Maintenance or designee. 5. **Quality Assurance:** Generator compliance will be tracked and reported to the QA Committee monthly starting April 2025 to ensure continued adherence and oversight. **Completion Date:** April 27, 2025
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications in accordance with the physician's orders for a resident, leading to a deficiency in following professional standards of practice. Specifically, a Licensed Practical Nurse (LPN) was observed preparing to administer medications to a resident and noted a discrepancy in the dosage of Vitamin D3. The Medication Administration Record (MAR) indicated that the resident was to receive 1000 International Units (IU) of D3 daily, as per the physician's orders. However, the medications available and administered were 2000 IU, which was not in accordance with the prescribed dosage. Further investigation revealed that the incorrect dosage of D3 had been administered on multiple occasions. Another LPN confirmed administering the 2000 IU dosage without altering the medication, and the Director of Nursing acknowledged awareness of the incorrect dosage being given. The facility's failure to adhere to the physician's orders for medication administration resulted in a deficiency, as the nurses did not follow the prescribed dosage for the resident.
Plan Of Correction
1. Physician order was clarified and updated to reflect 2000 units, consistent with the original dosage on. The dosage was administered on MARs audited facility-wide for compliance with physician orders initiated and completed. 2. Medication administration training initiated for licensed nurses; projected completion date. 3. Random audits twice weekly for 30 days led by DON or designee; pharmacy consultant monthly reviews, change in pharmacy services provider beginning. Reviewed in QAPI. 4. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date:
Failure to Implement Care Plan Leads to Resident Falls
Penalty
Summary
The facility failed to implement care plan interventions for a resident, leading to multiple incidents of falls and injuries. The resident, who was admitted with severe cognitive impairment and was dependent on staff for toileting, was observed being assisted by only one CNA, contrary to the care plan that required two staff members for toileting assistance. The CNA, who was an agency staff member, was not familiar with the facility's Kardex system and was not aware of the resident's specific needs for assistance. The resident experienced several falls, some resulting in minor injuries, due to inadequate supervision and assistance. The care plan was updated multiple times following these incidents, but the interventions were not consistently implemented. For instance, the use of floor mats requested by the resident's family was not documented in the care plan, and a planned training program for staff was not carried out. The resident's daughter expressed concern over the facility's inability to prevent further falls and injuries. Interviews with facility staff revealed a lack of training and communication regarding the resident's care needs. The MDS Coordinator confirmed that the care plan interventions, such as the use of two staff for toileting and the implementation of a training program, were not properly executed. The facility's failure to adhere to the care plan and ensure staff were adequately informed and trained contributed to the resident's repeated falls and injuries.
Plan Of Correction
1. Resident #120's care plan updated with two-person assist, mats, and implemented programming. 2. All high-risk residents' care plans reviewed, referrals made, and care plans updated as necessary initiated completed. 3. Staff re-educated on use of Kardex, interventions, and toileting support initiated with projected completion. 4. Daily review in clinical meeting, weekly audit at risk meeting ongoing and reported to QA committee monthly. Reviewed in QAPI. 5. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date:
Medication Administration Error: Incorrect D3 Dosage
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not administering medications as per the physician's orders for a resident. Specifically, the deficiency involved the administration of Vitamin D3 to a resident, where the prescribed dose was 1000 IU daily, but the resident was given 2000 IU instead. This discrepancy was observed when an LPN was preparing to administer medications and realized the need to clarify the order for D3. Despite the physician's order being for 1000 IU, the medication available and administered was 2000 IU. Further investigation revealed that the medication administration record indicated compliance with the physician's orders, but the physical medication cards showed otherwise. One card of D3 2000 IU had 29 tablets removed, while another card remained untouched. Interviews with the LPNs involved confirmed that the incorrect dose was administered on multiple occasions. The Director of Nursing acknowledged awareness of the issue and expressed the expectation that nurses follow the physician's orders.
Plan Of Correction
1. Physician order was clarified and updated to reflect 2000 units, consistent with the original dosage on. The dosage was administered on MARs audited facility-wide for compliance with physician orders initiated and completed. 2. Medication administration training initiated for licensed nurses; projected completion date. 3. Random audits twice weekly for 30 days led by DON or designee; pharmacy consultant monthly reviews, change in pharmacy services provider beginning. Reviewed in QAPI. 4. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date:
Failure to Implement Care Plan Leads to Resident Falls
Penalty
Summary
The facility failed to implement care plan interventions to prevent accidents and related injuries for a resident with multiple falls. The resident, who was severely cognitively impaired and dependent on staff for toileting, was observed being assisted by only one CNA, contrary to the care plan that required two staff members for toileting assistance. The CNA, who was an agency staff member, was not familiar with the facility's Kardex or the specific care requirements for the resident, leading to inadequate supervision during toileting. The resident had a history of multiple falls, some resulting in minor injuries, and was found on the floor on several occasions. Despite updates to the care plan, such as frequent checks and reminders for the resident to call for assistance, these interventions were not effectively communicated or implemented. The facility's failure to ensure that the care plan was followed and that staff were adequately trained contributed to the resident's repeated falls. Interviews with facility staff revealed gaps in training and communication regarding the resident's care needs. The Assistant Director of Nursing acknowledged that the CNA should have had a second staff member present during toileting to prevent accidents. Additionally, the use of mats requested by the resident's family was not documented in the care plan, and a planned training program for fall prevention was not implemented. These oversights highlight the facility's failure to provide adequate supervision and assistance devices to prevent accidents, as required by regulations.
Plan Of Correction
1. Resident #12's care plan updated with two-person assist, mats, and implemented programming. 2. All high-risk residents' care plans reviewed, referrals made, and care plans updated as necessary initiated completed. 3. Staff re-educated on use of Kardex, interventions, and toileting support initiated with projected completion. 4. Daily review in clinical meeting, weekly audit at risk meeting ongoing and reported to QA committee monthly. Reviewed in QAPI. 5. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date:
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure that the clinical records accurately reflected the advance directives for two residents. For the first resident, the clinical record indicated a full code status, despite the legal representative's preference for a different code status. The MDS Coordinator acknowledged the error but did not correct the code status in the medical record. The Director of Nursing and the Nursing Home Administrator confirmed that the required documentation for the preferred code status was missing, and the medical record was not updated accordingly. For the second resident, the clinical record also inaccurately reflected a full code status. The resident's son, who held power of attorney, indicated that the resident did not consistently comprehend healthcare decisions and preferred a different code status. The facility staff did not consult the son regarding the code status, and the Licensed Practical Nurse who admitted the resident documented a full code status without following up on the resident's preference. The Director of Nursing was unaware of the resident's indecision on code status due to a lack of documentation and communication. Both cases highlight a failure in the facility's process for verifying and documenting residents' advance directives. The facility did not ensure that the residents' or their representatives' preferences were accurately recorded and reflected in the medical records, leading to discrepancies in the documented code statuses.
Plan Of Correction
1. Resident #5 and #8 records updated to accurately reflect status and valid Florida yellow forms obtained. 2. Facility-wide audit of advanced directives completed. 3. Education commenced and completed on for clinical staff on federal and Florida requirements for advance directives. 4. Weekly audits for 4 weeks, then monthly for 3 months; reviewed in QAPI led by Social Worker or designee. 5. Report to QA committee will continue monthly for recommendations and or revisions. Reviewed in QAΑΡΙ. Correction completion date:
Care Plan Deficiencies in Resident Code Status and Safety Measures
Penalty
Summary
The facility failed to develop, implement, and revise care plans to meet the needs and preferences of three residents. For Resident #5, the care plan did not accurately reflect the resident's code status as decided by the healthcare representative. Despite the MDS coordinator documenting the representative's decision, the care plan was not updated, and the error was not caught by the Social Services Director. The Director of Nursing confirmed the care plan was inaccurate and did not reflect the resident's representative wishes. Resident #8's care plan also had deficiencies. The resident's son, who was involved in healthcare decisions, was not consulted about the resident's code status during the care conference. The care plan and physician's order incorrectly listed the resident as a full code, despite the resident and her son indicating otherwise. There was no documentation showing the resident's son was included in the development of the care plan for advance directives. For Resident #12, the care plan did not include the use of mats to minimize injury, despite being requested by the resident's daughter. The care plan also failed to specify the need for two staff members for toileting, which was necessary due to the resident's fluctuating abilities. CNA Staff B, who was assisting the resident, was not aware of the requirement for two staff members and had not been trained to access the Kardex for resident information. The Assistant Director of Nursing confirmed that the care plan interventions were not implemented as required.
Plan Of Correction
1. Resident #5, #8, and #12 care plans were updated to reflect code status, ADL needs, precautions, and toileting protocols. 2. Audit of all care plans initiated and completed. 3. IDT members re-educated on timely care plan development and revisions. 4. Weekly audits for 4 weeks, then monthly for 3 months; reviewed in QAPI, led by MDS Coordinator or designee. 5. Report to QA committee will continue monthly for recommendations and or revisions. Correction completion date:
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inn At Sarasota Bay Club | 2.4 mi | ★★★★★ | 0 | 0 |
| Sarasota Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Pines Of Sarasota | 2.8 mi | ★★★★★ | 2 | 0 |
| Indian Beach Nursing And Rehab Center | 3.1 mi | ★★★★★ | 4 | 0 |
| Sarasota Point Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
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