Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Place during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter and neurogenic bladder, care-planned as at risk for infection, was observed on multiple occasions with dark, cloudy urine and large white clumps of sediment in the catheter bag and tubing. Despite facility policy and staff training requiring monitoring, documentation, and immediate reporting of abnormal urine characteristics and potential UTI signs to a physician, no staff reported concerns, no assessments or physician notifications were documented, and nursing leadership was unaware of the catheter condition.
A resident with a recent right knee replacement and PRN oxycodone orders reported moderate to severe right leg pain on multiple occasions and requested stronger pain relief. An RN administered oxycodone as reflected on the controlled substance record, but did not document these administrations on the eMAR, instead recording low or no pain levels. No progress notes were entered to describe the resident’s pain complaints, pain site, pain level, or the assessment and monitoring of the opioid’s effectiveness or adverse effects, despite an active pain-related care plan and facility policies requiring comprehensive pain assessment and documentation.
Staff failed to follow hand hygiene, PPE, and enhanced barrier precautions during care. One RN administered sequential eye drop medications to a resident’s right eye without changing gloves or performing hand hygiene after handling the resident’s clothing and bedside items. An LPN donned gloves, handled a medication cart and computer, and then performed blood glucose monitoring on a resident using the same gloves without hand hygiene or glove change. Another resident with a stage 3 coccyx pressure injury lacked any order or care plan for enhanced barrier precautions, had no EBP signage or PPE outside the room, and a wound care APRN performed coccyx wound assessment without donning a gown, despite facility policy requiring EBP and PPE for residents with wounds requiring dressings.
The facility failed to maintain proper kitchen sanitation and food storage, affecting 77 residents. Observations included dented cans, unsealed and unlabeled food items, improper food storage order, and outdated food. Additionally, sanitization practices were inadequate, with a red sanitization bucket testing below the approved range. The facility lacked specific policies for storage and sanitization, contributing to the deficiencies.
The facility failed to assess and authorize self-administration of medications for four residents, who had medications at their bedsides without necessary physician orders or assessments. The DON admitted the lack of an assessment tool, and the facility's policy requiring written orders and assessments was not followed.
The facility failed to ensure a safe environment for residents at risk for falls, resulting in multiple incidents of improper transfer and positioning. A resident fell out of bed due to an unsecured mattress and inadequate supervision, while another had a call light out of reach and a floor mat not in place. Additionally, a resident was improperly transferred using a mechanical lift by a single staff member, contrary to policy. Lastly, a resident's bed and overbed table were not adjusted to a safe height, creating a fall risk.
The facility failed to maintain safe conditions by allowing sharps disposal containers in residents' rooms to overflow. Five residents' rooms were observed with containers filled beyond the full line, with sharp items on top. The DON confirmed that nurses are expected to dispose of containers once full, as per the facility's policy, which was not followed.
Two residents experienced discomfort due to a malfunctioning heating unit in their room, which had been reported on January 5, 2025, but remained unrepaired as of January 21, 2025. The facility's administrator confirmed the delay, despite a policy requiring urgent maintenance within 24 hours. The Director of Facilities noted the repair required the room to be vacant, which was not possible, leading to the continued issue.
Two residents experienced safety issues with their beds due to improper maintenance and oversight. One resident was on an air loss mattress that did not fit the bed frame, while another fell from bed due to an unsecured mattress. The facility's policy requires regular inspections, but these issues were not addressed promptly.
A resident with multiple health issues, including CHF and COPD, suffered neglect in wound care at a facility. Despite having a care plan, the wound care nurse failed to notify the physician about the resident's deteriorating toe wounds. The resident was discharged without proper assessment and later admitted to the hospital with gangrene, resulting in an above-the-knee amputation. Interviews revealed that staff noticed the toe discoloration but did not take appropriate action.
A resident with chronic wounds was not properly assessed or treated, leading to gangrene and an amputation. The wound care nurse failed to notify the physician and documented treatments that were not performed. This issue affected multiple residents, with inadequate wound care documentation and treatment observed across the facility.
Failure to Assess and Report Abnormal Urine and Catheter Findings
Penalty
Summary
The facility failed to assess, monitor, and provide timely medical interventions for a resident with an indwelling urinary catheter who exhibited signs consistent with possible urinary tract infection (UTI). The resident had multiple diagnoses, including neuromuscular dysfunction of the bladder and neurogenic bladder, and had an order for catheter care every shift. The care plan identified the resident as being at risk for infection related to the indwelling catheter and required staff to empty drainage bags regularly and monitor, record, and report signs and symptoms of UTI, such as cloudy urine and sediment. On two consecutive days, surveyors observed the resident’s catheter bag and tubing containing dark, cloudy yellow urine with large, thick white clumps of sediment. Despite these visible abnormalities, there were no corresponding progress note entries documenting the condition of the catheter, any assessment of the urine, or notification to the physician from the beginning of the month through the time of the survey. Staff interviews further demonstrated a lack of appropriate response to the resident’s catheter condition. A CNA reported being trained to look for blood, cloudiness, thickness, and darkness in catheter tubing or bags and to alert the nurse if such findings were present, but stated there were no observations or concerns regarding this resident’s catheter and no unusual occurrences reported from the previous shift. An agency LPN stated that signs of infection include sediment or blood in the tubing and cloudy urine, and that such findings should prompt a call to the physician for orders and urine testing, but reported being unaware of any concerns with the resident’s catheter and not receiving any report of sediment or cloudy urine. The DON stated that staff should observe for discoloration and other signs of potential infection and obtain physician orders when such signs are noted, and confirmed she had not been made aware of the resident’s catheter condition. Review of the facility’s urinary catheter care policy showed that staff are required to observe urine for unusual appearance, report findings to the physician and supervisor immediately, and document assessment data and urine characteristics, which was not done in this case.
Failure to Document and Monitor Opioid Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide and document safe, appropriate pain management for a resident following right knee replacement surgery. The resident was cognitively intact and had an admission MDS indicating occasional pain with an intensity of 5, with both scheduled and PRN pain medications ordered. The active orders included oxycodone 5 mg, with instructions to give 0.5 tablet for pain rated 4–6 and 1 tablet for pain rated 7–10. On two separate days, the resident reported significant right knee and lower leg pain, describing it as aching, throbbing, shooting, and constant, with self-reported pain scores ranging from 6/10 to 9/10. In both instances, the RN (V8) was notified of the resident’s pain complaints. On one day, the resident reported right knee and calf pain rated 6/10, and on another day, the resident reported severe right lower leg pain rated between 8 and 9/10, describing it as a new onset of constant, shooting pain and requesting a stronger pain medication (oxycodone) prior to therapy. The RN prepared and administered oxycodone 5 mg (1 tablet) in response to the resident’s complaint. The resident later reported that the oxycodone relieved some of the pain and allowed participation in therapy, although some pain remained. The facility’s electronic controlled substance record showed that the RN administered oxycodone 5 mg, 1 tablet, on both days in question. Despite the administration of oxycodone documented on the controlled substance record, the eMAR contained no entries showing that oxycodone was given on those days. Instead, the eMAR reflected pain levels of 2 and 0 on those dates, and there were no progress notes by the RN documenting the resident’s pain complaints, pain site, pain level, or any pain assessment. There was also no documentation of monitoring for effectiveness or adverse effects of the oxycodone that was administered, despite the resident’s care plan and facility policies requiring assessment, documentation of pain characteristics, monitoring of opioid effectiveness and side effects, and documentation of pain assessment results, medication, dose, route, and results. The DON confirmed that the oxycodone administrations were not documented in the eMAR and that there was no corresponding pain assessment or effectiveness monitoring in the medical record.
Failure to Follow Hand Hygiene, PPE, and Enhanced Barrier Precautions During Care
Penalty
Summary
The deficiency involves failures in hand hygiene and glove use during medication administration and blood glucose monitoring, as well as failures to implement enhanced barrier precautions and appropriate personal protective equipment during wound care. On February 24, 2026, a registered nurse prepared and administered Atropine 1% eye drops to the right eye of a resident (R10), then, while still wearing the same clean gloves, removed the resident’s sweater, placed it on the wheelchair, and handled puzzle papers and other bedside items. Without removing the gloves, performing hand hygiene, and donning a new pair of gloves, the nurse then opened and administered Prednisolone 1% eye drops to the same eye and dabbed under the eye and face with a tissue. The DON later stated that the nurse should have removed the dirty gloves, performed hand hygiene with alcohol rub/sanitizer, and applied new gloves before administering the second eye drop to prevent contamination, as required by the facility’s hand hygiene and glove-use policies. On February 23, 2026, an LPN prepared to check another resident’s (R68) blood sugar level while standing outside the resident’s room. The LPN donned gloves and, while wearing them, touched and opened the medication cart to obtain a lancet, locked the cart, and turned off/closed the computer attached to the cart. The LPN then entered the resident’s room and, using the same gloves, cleansed the resident’s left middle finger with an alcohol pad and performed the fingerstick to obtain blood for glucose monitoring. The DON later stated that the LPN should have removed the gloves used to handle the cart and computer, performed hand hygiene with alcohol rub/sanitizer, and then applied new gloves before performing the blood sugar monitoring procedure, in accordance with the facility’s policies that require hand hygiene immediately after glove removal and emphasize that glove use does not replace hand hygiene. A third resident (R88) had multiple diagnoses including Alzheimer’s disease, anxiety disorder, dysphagia, muscle weakness, a stage 3 pressure ulcer of the sacral region, and abnormal weight loss. Documentation showed a new unstageable coccyx pressure wound identified on December 8, 2025, later described as a stage 3 coccyx pressure injury. As of February 24, 2026, there was no physician order or care plan for enhanced barrier precautions (EBP) for this resident. Observations on February 23 and 24, 2026 showed there was no EBP signage on or around the resident’s room door and no personal protective equipment outside the room, despite the infection preventionist later stating that residents with chronic wounds or pressure ulcers should be on EBP. During coccyx wound care on February 24, 2026, a wound care advanced practice nurse entered the room and measured/assessed the open coccyx wound, approximately 2 centimeters in diameter, without donning a gown and while wearing a lab coat, leaning an arm on the resident’s bed, contrary to the facility’s EBP policy that requires PPE for high-contact resident care activities including wound care for residents with wounds requiring dressings.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 77 residents receiving dietary services. During a kitchen tour, several deficiencies were observed, including dented cans in dry storage, which were not removed as per facility policy. The walk-in freezer contained unsealed and unlabeled food items, such as chicken tenders and pumpernickel bread, contrary to the facility's policy requiring all food products to be appropriately wrapped, dated, or labeled. Further inspection revealed improper food storage practices in the dairy cooler, where whole turkey breast and flank steak were stored incorrectly over seafood, violating the facility's food storage chart order. Additionally, the reach-in freezer and refrigerator contained unlabeled and outdated food items, such as French onion soup and various dressings and canned fruits, which exceeded the facility's guidelines for storage duration. The third-floor kitchen's sanitization practices were also inadequate, with a red sanitization bucket testing at 0 ppm, below the approved range of 272 - 700 ppm. The facility lacked specific policies for dry storage, coolers, or freezers, relying instead on a storage chart. The Culinary Director acknowledged the importance of proper labeling and storage to prevent cross-contamination and ensure food safety, especially for residents with food allergies. However, the absence of logs for sanitization levels and the lack of specific facility policies contributed to the deficiencies observed.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for self-administration of medications and the storage of these medications at their bedsides. This deficiency was observed in four residents who had medications at their bedsides without the necessary physician orders or assessments. One resident had a generic pain-relieving cream with Lidocaine and a hemorrhoidal relief cream, both of which were not ordered by a physician and were kept at the bedside without proper authorization. Another resident had a tube of Ketoprofen gel, which was a compound medication made by a local pharmacy, but there was no physician order for its use or for it to be kept at the bedside. Similarly, a third resident had Clobetasol Propionate in their bathroom without any physician order or assessment for self-administration. The fourth resident, who had severe cognitive impairment, had Mobisyl pain-relieving cream on their shelving without any physician order or assessment for self-administration. The Director of Nursing (DON) acknowledged that the facility lacked an assessment tool to determine if it was appropriate for residents to have medications at their bedsides. The facility's policy required a written order from the prescriber and an assessment of the resident's self-administration skills by the interdisciplinary resident assessment team. However, these procedures were not followed, as evidenced by the lack of orders and assessments for the residents involved. The facility's policy also stated that unlabeled medications should be discarded or taken home by family members, but this was not adhered to in the observed cases.
Inadequate Fall Prevention and Unsafe Transfers in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment for residents at risk for falls, as evidenced by multiple incidents involving improper transfer and positioning. One resident, who was severely cognitively impaired and dependent on staff for bed mobility, fell out of bed due to an unsecured mattress and inadequate supervision. The resident's bed was positioned too close to the wall, and the mattress was not secured to the bed frame, contributing to the fall. Additionally, the staff member providing care did not ensure the bed wheels were locked, and the resident was left unattended momentarily, leading to the fall. Another resident was found with a folded floor mat not in place and a call light out of reach, despite being at risk for falls and having a recent fall incident. The facility's failure to implement fall prevention interventions, such as ensuring the call light was accessible and the floor mat was properly positioned, compromised the resident's safety. Furthermore, a resident who required a mechanical lift for transfers was improperly transferred by a single staff member, contrary to the facility's policy requiring two staff members for such transfers. This resulted in the resident sliding from the wheelchair and experiencing pain after the incident. Lastly, a resident who used a walker and wheelchair for mobility was observed with her bed and overbed table in a high position, creating a potential fall risk. Despite staff demonstrating the ability to lower both the bed and table to a safer height, the resident continued to raise the bed to reach items on the table. The staff's failure to ensure the resident's environment was adjusted to a safe height further exemplifies the facility's inadequate supervision and implementation of fall prevention measures.
Overflowing Sharps Disposal Containers in Resident Rooms
Penalty
Summary
The facility failed to maintain safe conditions in residents' rooms by allowing sharps disposal containers to overflow. During an initial tour, it was observed that five residents' rooms had sharps disposal containers filled beyond the indicated full line, with sharp items resting on top of the security flip lid. This situation was noted in the rooms of five residents, indicating a systemic issue with the management of sharps disposal. The Director of Nursing (DON) acknowledged that nurses are expected to monitor and dispose of sharps containers once they reach the full line. The facility's policy, dated January 2012, specifies that designated individuals should seal and replace containers when they are 75% to 80% full to prevent punctures and needlesticks. The failure to adhere to this policy resulted in the observed deficiency, compromising the safety of residents and staff.
Failure to Repair Heating Unit in Resident Room
Penalty
Summary
The facility failed to provide a warm and comfortable environment for two residents, identified as roommates, due to a malfunctioning heating unit in their room. The issue was first reported on January 5, 2025, but as of January 21, 2025, the heater had not been repaired. One of the residents expressed feeling extra cold because of the broken heater. The facility's administrator confirmed that the heating unit had been broken for more than a week and was still awaiting repair, despite the facility's policy that urgent maintenance work orders should be addressed within 24 hours. The Director of Facilities and Safety acknowledged receiving the maintenance work order on January 5, 2025, and noted that the temperature in the hallway was 72°F, but the temperature inside the room was not checked. The director also mentioned that the repair required the room to be vacant for approximately three hours, which was not possible on January 6, 2025, because one of the residents was present. The facility's policy emphasizes the importance of promptly addressing HVAC system issues to maintain a safe and comfortable environment for residents, but this was not adhered to in this instance.
Deficiency in Resident Bed Safety
Penalty
Summary
The facility failed to ensure the safety of resident beds, which led to deficiencies in the care of two residents. Resident R14, who is cognitively intact and requires substantial assistance with mobility, was observed on an air loss mattress that did not fit the bed frame properly, leaving approximately four inches of the bed frame exposed on each side. This issue persisted over multiple days, indicating a lack of immediate corrective action. The Director of Nursing acknowledged that direct care staff are responsible for ensuring bed safety and should report any issues to maintenance for immediate resolution. Resident R55 experienced a fall from bed due to a boundary mattress that was not secured to the bed frame. Staff members reported that the mattress shifted and slid off the frame, contributing to the fall. Upon assessment, it was found that the bed frame was missing a mattress security latch. Despite the facility's policy requiring regular inspections by maintenance and an outside vendor, these safety checks failed to identify and address the missing component. The facility's policy emphasizes the importance of maintaining beds to safety specifications and implementing additional safety measures for residents at higher risk of injury.
Neglect in Wound Care Leads to Severe Outcome
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not ensuring that the resident's non-healing, chronic wounds were assessed by a physician. The resident, who had multiple diagnoses including congestive heart failure, COPD, and cognitive communication deficit, was admitted to the facility with existing skin integrity issues. Despite having a care plan in place to monitor and report abnormalities in the resident's wounds, the facility staff did not notify the physician of the resident's deteriorating condition. The wound care nurse, identified as V3, repeatedly documented the resident's left toe wounds without differentiating which toes were affected or notifying the physician. The documentation showed consistent measurements of 1 cm by 1 cm for the wounds, but there was no evidence of physician notification or separate wound measurements for each toe. The attending physician, V8, was not made aware of the wounds, and the facility lacked documentation of any provider examining the resident from late October to the date of discharge in December. Upon discharge, the resident was admitted to the hospital with gangrene in the left toes, leading to an above-the-knee amputation. Interviews with facility staff revealed that the resident's toe discoloration was noted but not properly addressed or reported. The facility's failure to provide necessary medical care and notify the physician of the resident's condition resulted in a severe outcome, highlighting a significant neglect in the resident's care.
Inadequate Wound Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure proper wound care and assessment for a resident, leading to severe consequences. A resident with multiple diagnoses, including congestive heart failure and COPD, was admitted with chronic wounds on the left toes. Despite having a care plan in place, the wounds were not properly assessed or documented by the wound care nurse, who failed to notify the physician of the resident's condition. The nurse documented wound care treatments that were not performed, and the resident was discharged without a proper wound assessment. This negligence resulted in the resident being admitted to the hospital with gangrene, leading to an above-the-knee amputation. The facility's failure extended to other residents as well. Another resident with a left hip wound did not receive the prescribed wound care treatments due to the absence of the wound care nurse, who falsely documented that the treatments were completed. This pattern of inadequate wound care documentation and treatment was observed across multiple residents, with the nurse documenting treatments that were not performed and failing to delegate the responsibility to other staff members. The facility's policies on wound care documentation were not followed, as evidenced by the lack of proper recording of wound care procedures and the absence of physician notification. The attending physician was not informed of the resident's deteriorating condition, which contributed to the poor outcome. The facility's administrator acknowledged the discrepancies in documentation and the failure to provide appropriate care, highlighting systemic issues in the facility's wound care management.
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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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Nursing homes near La Grange Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Of Lagrange Park, The | 0.4 mi | ★★★★★ | 12 | 0 |
| Meadowbrook Manor - Lagrange | 0.9 mi | ★★★★★ | 4 | 0 |
| Bella Terra Lagrange | 1.6 mi | ★★★★★ | 0 | 0 |
| British Home, The | 1.8 mi | ★★★★★ | 0 | 0 |
| Aperion Care Westchester | 2 mi | ★★★★★ | 4 | 0 |
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