Below 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 Harborside Healthcare during CMS and state inspections, most recent first.
A resident with a history of elopement was able to exit through unlocked patio doors into an unsecured smoking area without staff awareness, despite a wander guard and a care plan for supervised smoking. Another resident was observed wearing clothing with burn holes and picking up cigarette butts from the ground to smoke them, while a third resident smoked with an oxygen concentrator and nasal cannula present in the smoking area. A fourth resident with recurrent falls was observed using a regular wheelchair cushion instead of the care planned wedge cushion.
The facility failed to use its QAPI process to develop PIPs for two identified issues: residents who required supervision when leaving the facility unattended and resident complaints about call light wait times. A resident with an activated HCP and prior unattended exit was observed outside alone with a wander guard, and residents reported delayed call light response times, including waits of over 30 minutes, but the facility had no measurable goals, tracked data, or PIP documentation for either concern.
A resident with Parkinson's disease had a neurology consult recommending Carbidopa/Levodopa, but the NP did not receive and act on the report until the family brought it in, delaying the medication start. Another resident with recurrent UTIs had a urology consult report that was not obtained or reviewed for weeks despite an order to obtain it. A third resident with diabetes was monitored with a CGM system, but staff did not know the device's care, sensor-change schedule, or maintenance requirements, and the DON said the facility did not use CGM systems.
Failure to Develop Trauma-Informed Care Plan: A resident with substance use disorder and cognitive impairment was observed scared and asking for help, while the care plan addressed behavioral symptoms but did not reflect a documented trauma history. The LMHC noted trauma related to drug use, living on the streets, and physical abuse, but the SS eval recorded no upsetting trauma experience and did not show further inquiry or individualized trauma-informed interventions.
Food Storage and Sanitation Deficiencies: The facility failed to follow food safety standards in the kitchen and two resident kitchenettes. Surveyors observed expired and undated food items, food stored on the floor in the walk-in refrigerator, and resident food left in kitchenette refrigerators beyond three days. A dirty food container, dirty fork, and debris were also found in a kitchenette cabinet, and the FSM stated food should be discarded after three days and cabinets kept clean.
Arbitration agreements for three residents were missing required language stating that the resident or representative could rescind within 30 days and that signing was not a condition of admission. Two residents said the admission paperwork was not explained to them, and an administrator acknowledged the wrong form had been used.
Arbitration Agreement Missing Required Neutral Arbitrator and Venue Terms: The facility failed to ensure arbitration agreements in admission packets for three residents included required language showing both parties would agree to a neutral arbitrator and a venue convenient to both parties. The Administrator reviewed the agreements and confirmed the missing components were not present on the forms signed by the residents or a resident representative, and stated the wrong version of the agreement had been used.
Oxygen concentrators were not maintained in a sanitary manner for two residents receiving O2 therapy. One resident’s concentrator was observed running without an external filter and with gray dust-like debris where the filter should have been, while another resident’s concentrator had cabinet filters covered with a thick layer of gray dust-like debris. Staff confirmed overnight shift was responsible for weekly cleaning of tubing and filters, and the DON stated each concentrator was expected to be clean with a clean filter in place.
A resident with COPD and intact cognition had inhalers at the bedside and stated a desire to self-administer them, including the rescue inhaler. Staff observed the resident using the inhalers, but the record lacked an IDT assessment, care plan, and physician order authorizing self-administration, and the DON and nurses acknowledged the resident had not been evaluated or ordered to self-administer.
A resident with depression and legal blindness, but cognitively intact, complained that loud hallway music outside the room was disrupting comfort and sleep, causing the resident to keep the door closed and wear headphones. The complaint was not recorded on the grievance log, and the Administrator said it was only a complaint because she addressed it right away, while the resident reported no meaningful resolution and continued to hear the music early in the morning.
A resident admitted with bipolar disorder, anxiety, and depression had a PASRR Level I screen that identified SMI for anxiety, but the mood disorder section for bipolar or major depression was not selected. When schizoaffective disorder was later added to the clinical record, staff and the Administrator confirmed that no new PASRR Level I screening was submitted through the PASRR Portal to reflect the resident’s updated mental health diagnoses.
A resident with Type II DM, legal blindness, insulin use, and a CGM order did not have a comprehensive care plan for diabetic care needs or CGM monitoring. The record showed orders for a controlled carbohydrate diet, CGM checks before meals and at bedtime, and diabetes medications, but the care plan did not address these needs. The DON acknowledged that the resident should have had a care plan for diabetes management and CGM use.
Failure to Follow Pressure Ulcer Orders: A resident with dementia and a stage 3 unhealed heel pressure ulcer had orders to offload the wound every shift, float the heels in bed, and apply a specific daily dressing. Surveyors observed the resident's heels flat on the mattress in bed on multiple occasions and the feet resting on wheelchair supports, and during wound care an incorrect bordered gauze dressing was used instead of the ordered bordered foam dressing. The UM, Infection Prevention Nurse, and DON confirmed the ordered heel offloading and dressing were not followed.
A resident with moderate cognitive impairment and a legal guardian repeatedly left the facility without staff knowledge or authorization, despite being assessed as at risk for elopement and requiring supervision. Staff and medical records documented multiple incidents where the resident was missing for extended periods, and interviews confirmed ongoing concerns about the resident's safety and lack of effective supervision.
A resident with dementia and a history of aggressive behaviors repeatedly physically assaulted and intruded upon other residents, including punching, entering others' beds, and becoming combative when redirected. Staff and other residents reported ongoing incidents despite awareness of the resident's behaviors and attempts at intervention, resulting in multiple instances where residents were not protected from physical abuse.
A resident with dementia and behavioral issues was involved in two separate altercations—one with a visitor and another with a CNA—neither of which were reported or investigated as required by facility policy. Despite staff and management being aware of the incidents, no incident reports were completed and the events were not reported to authorities.
Two residents with cognitive impairments and a history of safety concerns did not have the required magnetic stop sign intervention consistently implemented or documented in their care plans. Despite staff and family awareness of the need for this intervention to prevent wandering by another resident, observations and interviews revealed the stop sign was often missing, improperly placed, or not maintained, and staff were unclear about its use. Facility leadership was not consistently aware of the missing or improperly implemented interventions.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and missing interventions necessary for comprehensive care.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility failed to serve food at appetizing temperatures, as evidenced by test trays on two units. Residents complained about cold, salty, and unappetizing food, which was confirmed by test tray results showing lukewarm hot foods and inadequately chilled cold items. The Certified Dietary Manager acknowledged the deficiencies, noting that food temperatures did not meet the recommended standards.
A resident with a non-pressure wound did not receive appropriate treatment as per the wound doctor's recommendations. The facility's policy was limited to pressure ulcers, and there was no policy for non-pressure injuries. The treatment orders failed to include necessary components like Santyl ointment and dressing change frequency. Staff interviews revealed a lack of documentation and communication, leading to inconsistencies in the resident's wound care.
A resident with a stage four pressure ulcer did not receive appropriate care due to the facility's failure to accurately transcribe and implement the wound care physician's recommendations. Despite the physician's advice to apply a hydrocolloid sheet three times a week without additional dressing, the facility continued using a gauze island dressing daily. The wound nurse and unit manager acknowledged the transcription errors, and the DON considered this a medication error.
A resident with PTSD did not receive a person-centered care plan to address their trauma history and specific triggers, leading to a deficiency in trauma-informed care. The resident's preferences and coping strategies were not documented or communicated to staff, resulting in a lack of awareness and appropriate interventions. Interviews revealed that staff were not informed about the resident's PTSD triggers, and the care plan was not individualized to prevent re-traumatization.
A facility failed to maintain a medication error rate below 5%, with a nurse administering incorrect dosages to a resident due to unavailability of the correct medications in the cart. The errors included administering High Potency Slow-Release Iron 45 mg instead of Ferrous Sulfate 325 mg, Fish Oil 1200 mg instead of 1000 mg, and Vitamin D3 25 mcg instead of 125 mcg, resulting in an error rate of 11.54%.
The facility failed to follow food safety standards, with improperly labeled and expired food items found in the kitchen. Personal food was stored in resident areas, and CNAs did not perform proper hand hygiene during snack service, bringing the snack cart into resident rooms, which violated infection control protocols.
The facility failed to maintain an effective infection prevention and control program due to incomplete and inaccurate surveillance of infections. The Infection Preventionist (IP) relied on laboratory-supplied surveillance sheets and McGeer Criteria, but discrepancies were found in the documentation, with residents being started on antibiotics despite not meeting the criteria for infection. The IP, new to the position, was not adequately educated on tracking and trending illnesses, leading to an inaccurate reflection of infections within the facility.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for several residents. Antibiotics were prescribed to residents whose conditions did not meet the McGeer Criteria for infection, and there was no documentation that providers were informed of this inappropriate use. The IP admitted to documentation errors, and the DON confirmed the expectation for proper notification and documentation.
A resident admitted with multiple health conditions did not receive a summary of their baseline care plan within 48 hours, as required by facility policy. Despite being cognitively intact, the resident was unaware of their care plan details. Interviews revealed a lack of documentation and clarity among staff regarding the provision of the care plan.
A resident with a wedge compression fracture and dementia received incorrect medications due to unavailability in the medication cart. The nurse administered High Potency Slow-Release Iron 45 mg, Fish Oil 1200 mg, and Vitamin D3 25 mcg, which did not match the physician's orders. Interviews with staff confirmed these were medication errors, and the correct medications were not available in the storage room.
A resident with a suprapubic catheter was found with their urinary collection bag improperly positioned above the bladder and in contact with the floor, contrary to CDC guidelines. The facility lacked a specific policy on Foley catheter care, and staff acknowledged the improper positioning, which increased the risk of urinary tract infections for the resident, who had a history of frequent UTIs.
A resident with COPD and other respiratory conditions experienced a deficiency in care due to improper maintenance and storage of respiratory equipment. The BiPAP mask and tubing were not stored properly, and the oxygen concentrator was covered in dust and debris. Staff interviews revealed a lack of specific orders or policies for cleaning and maintaining the equipment, leading to potential contamination risks.
A resident was prescribed Ativan PRN for anxiety without a stop date, exceeding the 14-day limit required by CMS guidelines. Despite facility policy and pharmacy recommendations, the order was not reevaluated or documented with a rationale for extension. Interviews with staff revealed a lack of adherence to the process for addressing pharmacy recommendations, leading to the resident receiving unnecessary medication.
A facility failed to obtain a Level II PASARR for a resident with major depressive disorder, paranoid schizophrenia, and dementia, who transferred in 2019. The necessary documentation was missing, and the DON was unaware of the resident's need for additional services. The MassHealth PASARR office confirmed no record of a Level II PASARR, indicating non-compliance with PASARR requirements.
Unsafe smoking supervision and fall intervention failures
Penalty
Summary
The facility failed to ensure adequate supervision and an environment free of accident hazards for multiple residents. Resident #80, who had a history of elopement, a wander guard, and care plan directions for supervised smoking, was observed exiting through newly opened patio doors into an unsecured smoking area without staff awareness. The patio doors did not have a wander guard alert system, the gate from the smoking area to the parking lot was left open, and staff stated they would not know if the resident left through those doors unless someone saw it happen. The Administrator and DON acknowledged the doors were opened before safety measures were in place and that Resident #80 should not have been outside unsupervised. Resident #80 was also observed in the smoking area taking another resident’s cigarette to light his/her own cigarette, despite a smoking evaluation stating the resident was safe to smoke only with supervision and safe to light a cigarette only with staff assistance. Resident #15, who had moderate cognitive impairment and used tobacco, was observed wearing clothing with numerous burn holes and was later seen picking up cigarette butts from the ground in the smoking area and lighting them on the stationary electronic lighter. The smoking area contained many cigarette butts on the ground and in the snow, and the active care plan did not include information about the resident wearing clothing with burn holes. Resident #82, who had COPD, used oxygen and tobacco products, was observed exiting to the smoking area with an oxygen concentrator attached to the ambulatory device and a nasal cannula in place, then lighting a cigarette. The resident later was again observed smoking while the oxygen concentrator hung from the walker, and staff stated there was no plan for where the concentrator should be stored during smoking. Resident #84, who had a history of recurrent falls and had a care planned wedge cushion for the wheelchair, was observed in the wheelchair with a regular cushion instead of the wedge cushion. After additional falls, staff reviewed the resident and environment, but the wedge cushion was not in place when the resident was observed by the surveyor.
QAPI Lacked PIPs for Elopement Supervision and Call Light Wait Times
Penalty
Summary
The facility failed to set priorities for an effective QAPI program and did not develop a performance improvement project to track, investigate, analyze, and use data related to residents who required supervision when leaving the facility unattended and to resident concerns about call light wait times. The facility’s QAPI policies stated that data should be reviewed to identify problems, prioritize challenges, set goals, monitor progress, and evaluate the effectiveness of interventions, and that resident and family concerns should be addressed through the QAPI process. However, the Administrator stated there was no PIP for the surveyor to review for either issue, and there were no measurable goals or documented data to show how success was being measured. For the elopement-related concern, the facility had developed a plan of correction in December 2025 after a resident left the facility unattended, and on 2/10/26 Resident #80 was observed outside in the opened courtyard near the parking lot with a wander guard on the wrist and no staff supervision. Nurse #1 stated the resident should have been supervised and should not have been outside alone. The medical record showed the resident had an activated Health Care Proxy and had previously left the facility unattended in October 2025. For call light wait times, Resident Council minutes from November 2025 and January 2026 documented resident complaints that call lights were not always answered in a timely manner, and during a group meeting 7 of 14 residents said they had waited over a half hour. The Activities Director said concerns were verbally shared with the Administrator, and the Administrator said staff education, lunch and learns, and weekend audits were done, but there was no documentation to analyze, measure, or track the audit data and no PIP for surveyor review.
Delayed consultant follow-up and improper CGM monitoring
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with Parkinson's disease and dementia when a neurology consultant recommended a trial of Carbidopa/Levodopa, but the Nurse Practitioner did not receive or review the consultant summary in a timely manner. The resident returned from the neurology appointment with documentation noting deterioration in function and memory and recommending Carbidopa/Levodopa 25/100 mg twice daily, then three times daily. Nursing documentation indicated the NP was notified the evening of the appointment, but the medication was not initiated until 22 days later after the resident's family member brought the neurology report to the facility and the NP reviewed it. The facility also failed to obtain and review a urology consultant report for a resident with benign prostatic hyperplasia, urinary tract infections, and urinary retention. The NP had written an order requesting the urology visit summary be obtained and placed in the provider book for review, and nursing documentation showed a call was made to the urology office requesting the report. However, the report was not present in the medical record when reviewed by surveyors, and the consultant note from the 12/12/25 visit was not received in the building until 57 days after the visit. The urology note included recommendations related to recurrent urinary tract infections, including cranberry supplements and consideration of suppressive antibiotics and methenamine hippurate. The facility failed to monitor and manage a resident's continuous glucose monitor according to the manufacturer's instructions and had no policy for CGM use. The resident, who was legally blind and had diabetes mellitus with insulin use, was being monitored by staff using the CGM system rather than finger sticks, but staff members stated they did not know who monitored the sensors, who changed them, how often they were changed, or where supplies came from. The DON stated the facility did not use CGM systems in the building and was not aware the resident's blood glucose was being monitored only through the CGM. The resident stated the sensor was changed every two weeks by self, but did not demonstrate cleaning the site or rotating the sensor location, and staff did not know the care or maintenance requirements for the device.
Failure to Develop Trauma-Informed Care Plan
Penalty
Summary
The facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for one resident with a history of trauma. The resident was admitted with diagnoses of substance use disorder and cognitive impairment and was observed sitting across from the nurses’ station stating he/she was scared and asking for help. A nurse stated the resident always said he/she was scared and that this was the resident’s behavior. The care plan addressed behaviors such as wandering, pacing, refusing care, yelling, physical aggression, verbal abuse, disruptive sounds, and disrobing in public, with interventions focused on medications, anticipating care needs, activity programs, a non-confrontational environment, and reducing stressors such as calling the sister. The medical record showed the LMHC documented a history of trauma beginning with the 11/5/25 visit and in subsequent visits, including references to trauma related to drug use and living on the streets. However, the Social Service Evaluation’s trauma-informed care assessment stated the resident had not ever had an experience so upsetting it changed him/her emotionally, spiritually, physically, or behaviorally, and no further trauma information was documented. The record did not show that Social Services inquired further with the resident or the sister about the trauma noted by the LMHC. The LMHC later stated he had reached out to the sister, who reported the resident had a history of physical abuse, and the DON stated the history of trauma should have been included on the Social Service Evaluation and care planned with interventions.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in the main kitchen walk-in refrigerator. On 2/9/26, the surveyor observed a metal container with sliced tomato and lettuce that had a pinkish discoloration, a prep date of 1/30/26, and a use-by date of 2/4/26; a metal container holding four small clear plastic containers dated 1/21 with white chopped onions; two trays with prepared cole slaw and plastic containers that were undated; a pouch of whipped cream without an open date; and four boxes of juice cups stored on the floor under the bottom shelf. On 2/11/26, the surveyor observed two boxes of half-gallon milk products stored on the floor of the walk-in refrigerator. During interview, the Food Service Manager stated the boxes should not have been stored on the floor and that food should be discarded after three days. The facility also failed to ensure proper handling of resident food in two kitchenettes and failed to keep food storage cabinets clean. In the second-floor kitchenette, the surveyor observed a white takeout container with a resident's name dated 2/7/26 in the refrigerator, and a plastic food container on the bottom left shelf cabinet that was soiled with sauce, a dirty fork, and debris on the shelf. In the first-floor kitchenette, the surveyor observed a white bag labeled with a resident's name dated 2/6/26 in the refrigerator containing a black banana, a Styrofoam container with a piece of cake, pre-packaged items, orange juice, fruit cups, and numerous condiment packets. On 2/13/26, the surveyor and Food Service Manager observed the same resident food still in both kitchenettes and the same dirty container in the second-floor kitchenette. The Food Service Manager stated that staff checking refrigerator temperatures in the morning should remove food older than three days and that the cabinets should be kept clean.
Arbitration Agreement Missing Required Admission Language
Penalty
Summary
The facility failed to ensure the Arbitration Agreement included required information for three residents in the sample reviewed. For Resident #75, admitted in January 2026, the resident said no one explained the admission paperwork and that paperwork was simply handed to him/her to sign. The signed Arbitration Agreement did not explicitly state that the resident could rescind the agreement within 30 days or that signing was not required as a condition of admission. For Resident #85, admitted in December 2025, the resident said no one told him/her about arbitration or the 30-day rescission period and that the admission paperwork was not reviewed with him/her. The signed Arbitration Agreement also lacked language stating the resident could rescind within 30 days and that signing was not required for admission. For Resident #59, the representative said the admission paperwork, including the Arbitration Agreement, had been reviewed, but the signed agreement still did not explicitly state the 30-day rescission right or that signing was not a condition of admission. The Administrator said she reviewed admission packets and arbitration agreements, but acknowledged the agreements signed by these residents did not contain the required components and that she had been using an incorrect version of the form.
Arbitration Agreement Missing Required Neutral Arbitrator and Venue Terms
Penalty
Summary
The facility failed to ensure the Arbitration Agreement presented to residents as part of the admission packet included required information for three residents: Resident #75, Resident #85, and Resident #59. Record review showed that the Arbitration Agreement signed by Resident #75 on 1/8/26 did not indicate that both parties would agree to a neutral arbitrator or to a venue convenient to both parties. The Arbitration Agreement signed by Resident #85 also did not include those required elements, and the agreement signed by the representative of Resident #59 on 1/23/26 likewise failed to show agreement on a neutral arbitrator and a convenient venue. During the entrance conference, the Administrator stated the facility had asked residents to enter into a binding arbitration agreement. In a later interview, the Administrator said she was responsible for reviewing admission packets and had been reviewing Arbitration Agreements. She provided a blank admission packet that included Attachment M, Arbitration Agreement, but after reviewing the agreements for all three residents, she said she could not find where they indicated both parties would agree to a neutral arbitrator and a venue convenient to both parties. She later stated there was a more up to date Arbitration Agreement developed in February 2025, but she had not been using the correct one, and confirmed the required components were not listed on the agreements signed by Resident #75, Resident #85, and the representative for Resident #59.
Oxygen Concentrators Not Maintained in a Sanitary Manner
Penalty
Summary
The facility failed to maintain oxygen concentrators in a sanitary manner for two residents who were receiving oxygen therapy. One resident was admitted with COPD, shortness of breath, and continuous oxygen use, and had a physician order to receive oxygen at 2 L/min continuously with weekly cleaning of the concentrator and filters. Surveyors observed that this resident’s oxygen concentrator was running without an external filter on multiple occasions, and gray dust-like debris was present where the filter should have been. The resident stated the concentrator should have had an external filter, but it did not, and staff members who observed the equipment were unsure whether the concentrator needed a filter. A second resident was admitted with dependence on supplemental oxygen, COPD, chronic respiratory failure, and shortness of breath, and had an order for continuous oxygen at 3 L/min with weekly cleaning of the concentrator and filters. Surveyors observed this resident’s oxygen concentrator in use with the left and right cabinet filters covered with a thick layer of gray dust-like debris on multiple occasions. The resident’s February TAR showed the concentrator had been wiped down and the filter cleaned on two dates, but the survey observations documented dirty filters still in place during the survey period. Interviews with nursing staff and the Staff Development Coordinator/Infection Preventionist confirmed that overnight staff were responsible for changing tubing and cleaning or washing oxygen filters weekly. The DON stated the expectation was that each oxygen concentrator should be clean and have a clean filter in place. Despite these expectations, one resident’s concentrator was observed without a filter and with debris in the filter area, and the other resident’s concentrator was observed with visibly dirty filters.
Failure to Assess and Order Self-Administration of Inhalers
Penalty
Summary
The facility failed to ensure one resident was assessed by the interdisciplinary care team for self-administration of medications and had a physician's order to self-administer. The resident was admitted with diagnoses including COPD and shortness of breath, and the MDS dated 1/23/26 showed the resident was cognitively intact with a BIMS score of 15 out of 15. The facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, and staff/provider assess the resident's mental and physical abilities and document the findings and resident choices. During multiple observations, the resident had inhalers at the bedside, including Breztri Aerosphere, Salmeterol, and Albuterol, and stated a preference to administer the inhalers independently, especially the Albuterol rescue inhaler. Nursing staff acknowledged the resident had not been assessed for self-administration and did not have an order to self-administer the inhalers. The medical record did not include a care plan for self-administration or a physician's order authorizing the resident to self-administer medications.
Failure to Process Resident Complaint as a Grievance
Penalty
Summary
The facility failed to ensure a resident’s grievance regarding loud music playing from a hallway ceiling speaker outside the resident’s room was properly handled, tracked, and resolved according to facility policy. The resident was admitted with diagnoses including depression and legal blindness and had a BIMS score of 15 out of 15, indicating cognitive intactness. The resident reported keeping the door closed because the hallway radio speaker was loud and said the music came on early in the morning and stayed on all day, requiring the resident to wear headphones and keep the room door shut to block the sound. The resident also stated the Administrator had not done anything about the concern. The facility’s grievance log for January and February did not show a grievance for the music complaint. During interview, the Administrator acknowledged the resident had raised the issue and said the music at 6:00 A.M. was too early, but stated she considered it a complaint rather than a grievance because she addressed it right away. The resident later stated the Administrator never spoke to him/her about any change to the music schedule and said the music was still on early in the morning. Both the surveyor and the CCCO heard the music coming from the hallway speaker during the interview.
PASRR Screening Not Updated for Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate PASRR screening for one resident with mental health diagnoses. The resident was admitted in September 2022 with bipolar disorder, anxiety, and depression, and the PASRR assessment completed at admission identified a serious mental illness for anxiety, but the mood disorder section for bipolar or major depression was not selected on the intake form. The resident’s clinical record later showed a physician order dated 2/5/24 to add schizoaffective disorder, and the diagnosis list was updated to include schizoaffective disorder on 2/6/24. Review of the PASRR Portal and interviews with staff and the Administrator confirmed that a new PASRR Level I screening was not submitted after the bipolar disorder diagnosis was omitted from Section B at admission and after the schizoaffective disorder diagnosis was added to the record.
Failure to Care Plan Diabetes Management and CGM Use
Penalty
Summary
The facility failed to develop, implement, and individualize a comprehensive care plan for one resident with Type II DM, out of a sample of 20 residents. Resident #39 was admitted in November 2025 with diagnoses including Type II diabetes mellitus with proliferative diabetic retinopathy with macular edema of the right eye, traction retinal detachment involving the macula of the left eye, legal blindness, and long-term insulin use. The resident had physician orders for a consistent/controlled carbohydrate diet, a CGM before meals and at bedtime, Jardiance 25 mg in the evening, Lantus 18 units subcutaneously in the evening, and Metformin ER 750 mg, two tablets daily. Review of the comprehensive care plans showed no care plan developed for the resident’s diabetic care needs or for monitoring and use of the CGM. The facility’s care plan guidance stated that each resident should have a comprehensive, person-centered care plan with objectives that meet physical, psychosocial, and functional needs, identify problem areas and causes, and be revised as the resident’s condition changes. During interview, the DON stated she would expect a resident with Type II DM to have a care plan for care and monitoring, and acknowledged that Resident #39 should have a care plan addressing diabetic needs, including the CGM, but did not have one.
Failure to Follow Pressure Ulcer Orders
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a left heel pressure ulcer. Resident #71 was admitted with dementia and a pressure ulcer of the left heel, and the MDS indicated a stage 3 unhealed pressure ulcer present on admission. Physician orders directed staff to offload the wound every shift, float the heels in bed every shift, and apply a specific wound dressing daily to the left lateral heel using normal saline, iodosorb, and a bordered foam dressing. The care plan and wound consultant recommendations also included treatment as ordered, floating heels in bed, and offloading wounds. Survey observations showed the resident lying in bed with both heels flat on the mattress on multiple occasions and sitting in the wheelchair with both feet resting on foot buddy/leg supports. On 2/11/26, the surveyor observed wound care being provided and noted that a white bordered gauze dressing had been applied instead of the ordered bordered foam dressing. During interviews, the Unit Manager and Infection Prevention Nurse stated the resident's heels should have been offloaded and not resting on the mattress, and the Unit Manager said the incorrect dressing had been applied. The DON stated physician orders should be followed as indicated and that the heels should have been offloaded or floating and the correct dressing applied.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with moderate cognitive impairment, a legal guardianship in place, and a history of leaving the facility without notifying staff was not provided with adequate supervision to prevent elopement. The resident was assessed as being at risk for elopement and required supervision for ambulation. Despite this, multiple nurse's notes documented several occasions where the resident left the facility without signing out, was seen in the community or along the roadway, and staff were unaware of the resident's whereabouts for extended periods. Staff interviews confirmed that the resident was frequently noncompliant with supervision, ambulated outside alone, and was not fully understanding the risks involved. Concerns about the resident's safety and cognitive status were noted by both nursing and medical staff, with cognitive testing ordered to further assess the situation. The facility's elopement policy required staff to determine if a resident was out on authorized leave and to notify administration if not. However, documentation and interviews revealed that staff were often unaware when the resident left, and the required notifications and interventions were not consistently implemented. The Director of Nursing and Administrator acknowledged the resident's inability to safely leave the facility alone and that the guardianship arrangements were not sufficient to ensure safety. Despite repeated incidents and staff concerns, the resident continued to elope without adequate supervision or effective preventive measures in place.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by not adequately preventing a resident with a known history of aggressive and intrusive behaviors from harming others. The resident in question, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, and anxiety, exhibited frequent physical and verbal aggression, wandering, and rejection of care. Despite these behaviors being documented in the resident's admission assessment, the facility did not implement sufficient measures to prevent repeated altercations with other residents. Multiple incidents occurred over several months in which the resident physically assaulted or intruded upon other residents. These included a witnessed event where the resident punched another resident in the stomach and chest, entering and sleeping in other residents' beds, and an unwitnessed altercation where a resident reported being punched on the arm and face. Staff and other residents confirmed that the resident frequently wandered into others' rooms, became combative when redirected, and had a pattern of aggressive behavior towards both staff and residents. Interviews with CNAs, nurses, and the unit manager revealed that staff were aware of the resident's behaviors and the ongoing risk posed to others. Although some interventions such as redirection and magnetic stop signs were mentioned, the repeated incidents indicate that these measures were not effective in ensuring the safety of other residents. The facility's failure to adequately supervise and manage the resident's behaviors resulted in multiple instances where other residents were not protected from physical abuse.
Failure to Report and Investigate Resident Altercations
Penalty
Summary
The facility failed to report and investigate two separate incidents involving a resident with Alzheimer's disease and behavioral disturbances. In the first incident, a family member reported to the unit manager and executive director that he pushed the resident with his fingers to redirect the resident out of another resident's room. Despite the facility's policy requiring the reporting and investigation of all alleged abuse, no incident report was completed, and the event was not reported to the Department of Public Health. The unit manager acknowledged that the incident should have been reportable, but after discussion with the corporate team, no further action was taken. In the second incident, a certified nurse aide reported being punched in the face by the same resident while providing evening care. The aide informed the nurse on duty, but was not asked to write a statement, and no incident report was completed. The nurse stated she followed the unit manager's instructions, who did not recall the incident or confirm whether an incident report would have been initiated. The executive director was not made aware of this event. The facility's executive director confirmed that it is the expectation that all altercations be followed by an incident report and proper reporting, which did not occur in these cases.
Failure to Consistently Implement and Document Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to develop and consistently implement care plan interventions for two residents who required a magnetic stop sign across their doorways to minimize the risk of other residents wandering into their rooms. One resident, with diagnoses including legal blindness, a history of falls, and dementia, had a care plan that did not document the use of a magnetic stop sign, despite staff informing the family that this intervention was in place. Multiple observations revealed that the stop sign was either not present or not properly secured, and staff interviews indicated a lack of awareness or understanding regarding the intervention's consistent use and maintenance. Another resident, diagnosed with dementia with psychotic disturbances, major depression, and anxiety, had a care plan that included the use of a magnetic stop sign as an intervention. However, during several observations, the stop sign was not present across the resident's doorway. Staff interviews revealed confusion about whether the intervention was ever implemented or if it was only intended as a temporary measure. The absence of the stop sign was noted despite documentation and staff acknowledgment that it was required for the resident's safety. Throughout the survey, it was observed that the resident who was known to wander continued to do so without purpose or direction, and there were documented incidents of this resident entering the rooms of others, including those who were supposed to be protected by the stop sign intervention. Facility leadership and staff were not consistently aware of the care plan requirements or the status of the interventions, resulting in a failure to follow and document the necessary safety measures as outlined in the residents' care plans.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not include all necessary interventions or clearly defined goals and timelines for meeting the resident's needs.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at appetizing temperatures, as evidenced by the results of two test trays conducted on two separate units. The facility's policy on Trayline and Meal Delivery, revised in June 2018, mandates that meals be assembled attractively and delivered within established mealtimes to maintain palatability and food safety. However, during a Resident Group meeting, several residents complained about the food being served cold, salty, and unappetizing. These complaints were substantiated by the test tray results, which showed that food items were served at temperatures below the recommended range, with hot foods being lukewarm and cold items not sufficiently chilled. On the first test tray conducted on the 1st Floor Unit, the chicken parmesan, pasta, ground chicken, pureed chicken, and mashed potatoes were all served lukewarm, with temperatures ranging from 118.0 to 128.5 degrees Fahrenheit. Similarly, the second test tray on the 2nd Floor Unit revealed that scrambled eggs, waffles, ground meat sausage, pureed bread, and pureed eggs were served at inadequate temperatures, with some items being cold and unappetizing. The Certified Dietary Manager (CDM) acknowledged the deficiencies, agreeing with the surveyor's findings and noting that the hot food temperatures should have been between 125.0 and 135.0 degrees Fahrenheit, while cold items should be between 42.0 and 43.0 degrees Fahrenheit upon arrival at the units.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident with a non-pressure wound received the necessary treatment and services to promote healing. The resident, who had a history of heart disease and diabetes mellitus with neuropathy, was admitted to the facility in December 2021. The resident's wound on the right first toe was being followed by a wound doctor, who provided specific treatment recommendations. However, the facility did not implement these recommendations accurately, as evidenced by the absence of Santyl ointment in the treatment orders and the failure to include the recommended dressing change frequency. The facility's policy on skin care was limited to pressure ulcers, and there was no policy for general skin care or non-pressure injuries. The Service Agreement with the Wound Care Provider required the facility to support wound care services, including informing the primary care provider of recommendations within 24 hours. Despite this, the facility's nursing and physician progress notes did not indicate any communication with the physician regarding the wound doctor's recommendations or any refusal of these recommendations by the physician. Interviews with staff revealed a lack of clarity and documentation regarding the wound care orders. The Staff Development Coordinator, who was responsible for writing the orders, acknowledged the discrepancies between the orders and the wound doctor's recommendations. The Director of Nurses confirmed that the orders should match the wound physician's recommendations and that any deviations should be documented. The lack of documentation and communication led to inconsistencies in the resident's wound care treatment, contributing to the deficiency.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a stage four pressure ulcer on the left heel. The resident, who was admitted with diagnoses including Type II diabetes mellitus with diabetic neuropathy, was cognitively intact and dependent on staff for assistance with bed mobility. The facility's policy required that residents with pressure ulcers receive necessary treatment and services consistent with professional standards to promote healing and prevent infection. However, the facility did not accurately transcribe and implement the orders for changes in treatments as recommended by the wound care physician. The wound care physician recommended the use of a hydrocolloid sheet to be applied three times per week without additional dressing. Despite this, the facility continued to apply a gauze island dressing daily, contrary to the physician's recommendation. The physician's orders were not updated to reflect the wound care physician's recommendations, and the gauze island dressing was not discontinued as advised. This discrepancy persisted over several weeks, with the treatment administration record failing to indicate the correct order. Interviews with the wound nurse and unit manager revealed that the wound physician's recommendations were communicated but not accurately transcribed into the resident's medical record. The wound nurse admitted to entering the order incorrectly, and the unit manager acknowledged noticing the error but failing to document the correction. The Director of Nursing stated that administering the wrong treatment is considered a medication error, highlighting the facility's failure to ensure timely and accurate transcription of the wound physician's recommendations.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop a person-centered plan of care for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD), which led to a deficiency in providing trauma-informed care. The resident, who was cognitively intact, had diagnoses including spastic hemiplegic cerebral palsy, anxiety disorder, bipolar disorder, and PTSD. Despite the facility's policy on trauma-informed care, the care plan for the resident was not individualized to include specific interventions to mitigate triggers that could cause re-traumatization. Interviews with the resident revealed that they had specific triggers such as certain noises and smells, including the sound of an ambulance door alarm, which were not addressed in their care plan. The resident expressed discomfort with male therapists and preferred female staff during certain care activities, yet these preferences were not documented or communicated to the staff. The resident also reported that staff had not inquired about their triggers or coping strategies until prompted by the surveyor's intervention. Staff interviews indicated a lack of awareness regarding the resident's history of trauma and specific triggers. The care plan was generated from a template and did not reflect the resident's individual needs or preferences. The Director of Nursing acknowledged that the care plan should have been person-centered and included specific interventions to prevent re-traumatization, but this was not the case. The deficiency highlights a failure in the facility's implementation of trauma-informed care practices, as staff were not adequately informed or trained to address the resident's PTSD and related needs.
Medication Error Rate Exceeds 5% Due to Incorrect Dosages
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as observed during a medication pass where one of two nurses made three errors out of 26 opportunities, resulting in an error rate of 11.54%. The errors were identified during the administration of medications to a resident with a history of wedge compression fracture and dementia. The medications administered did not match the physician's orders, leading to discrepancies in the dosage and type of medication given. Specifically, the nurse administered High Potency Slow-Release Iron 45 mg instead of the prescribed Ferrous Sulfate 325 mg, Fish Oil 1200 mg instead of 1000 mg, and Vitamin D3 25 mcg instead of 125 mcg. The nurse admitted to administering these incorrect doses because they were the only ones available in the medication cart. The Unit Manager and Director of Nurses confirmed that these were medication errors, as the administered doses did not align with the physician's orders.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety, which could potentially lead to foodborne illnesses among residents. During an inspection of the main kitchen's walk-in refrigerator, numerous food items were found improperly labeled or not labeled at all, with some items not discarded despite being past their use-by dates. The Certified Dietary Manager (CDM) acknowledged these lapses, noting that items such as salami, chicken breasts, and various prepared foods were not properly labeled or disposed of in a timely manner, as per the facility's policy. Additionally, the facility did not ensure that personal food items were kept separate from resident nourishment areas. A surveyor discovered a plastic bag containing unknown frozen items in the 2nd Floor Unit nourishment kitchen, which was later identified as belonging to a staff member. This contravenes the facility's policy that prohibits staff from storing personal food in areas designated for resident use. The facility also failed to maintain proper hand hygiene practices during meal service. Observations revealed that CNAs did not perform hand hygiene between serving snacks to different residents and brought the snack cart into resident rooms, which is against infection control protocols. The Director of Nurses confirmed that these actions were inappropriate and highlighted the need for CNAs to sanitize their hands between serving residents and to avoid bringing the snack cart into resident rooms.
Inaccurate Infection Surveillance and Documentation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete surveillance of infections. The facility's policy on infection surveillance, revised in July 2024, aimed to identify individual cases and trends of significant organisms and healthcare-associated infections. However, the Infection Preventionist (IP) relied on laboratory-supplied surveillance sheets and McGeer Criteria to document illnesses, but the surveillance listings were found to be incomplete and inaccurate. For instance, the surveillance listing for a resident did not indicate all criteria were met for an illness to be counted as an infection, and symptoms were not documented, rendering the surveillance sheet incomplete. The facility's use of McGeer Criteria was inconsistent, as evidenced by the inaccurate completion of criteria documents for residents. In July 2024, all 14 residents who met the criteria were started on antibiotics, but the surveillance listing for one resident failed to meet all criteria for an infection. Similarly, in August and September 2024, discrepancies were noted in the surveillance listings, with residents being started on antibiotics despite not meeting the McGeer criteria for infection. The IP admitted to not tracking residents with symptoms that did not require antibiotics and acknowledged inaccuracies in the McGeer criteria documentation. Interviews with the IP and the Director of Nursing (DON) revealed a lack of proper tracking and trending of illnesses. The IP, new to the position, was not educated on tracking and trending illnesses and relied on nursing reports and progress notes to track antibiotic use. The DON expected the IP to track all illnesses to identify trends, but improvements were needed to ensure accurate completion of McGeer criteria. The failure to accurately track and document infections led to an inaccurate reflection of infections within the facility.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required, which led to inappropriate antibiotic use for several residents. The facility's policy outlined that the infection preventionist (IP) or designee should review clinical infections treated with antibiotics and notify the provider if the use did not meet the McGeer Criteria for active infection. However, the review of surveillance sheets and progress notes for July, August, and September 2024 revealed that antibiotics were prescribed to residents whose conditions did not meet the criteria for an infection. Specifically, Resident #12 was treated with antibiotics despite the surveillance indicating no infection, and there was no documentation that the provider was informed of this inappropriate use. Similarly, Resident #58 and Resident #51 were prescribed antibiotics for conditions that did not meet the infection criteria, and again, there was no evidence that the providers were notified of the continued antibiotic use. During interviews, the IP admitted to incorrectly documenting the surveillance listing for Resident #12 and acknowledged the lack of documentation for notifying the providers about the inappropriate antibiotic use for all three residents. The Director of Nursing (DON) confirmed that the expectation was for the IP to notify the physician when antibiotics were ordered without meeting the criteria and to document the notification and response in the nursing progress notes.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with multiple diagnoses including atrial fibrillation, dementia, neuropathy, cerebrovascular accident, and coronary artery disease, reported not receiving any information about their care plan. Despite being cognitively intact, as indicated by a BIMS score of 13 out of 15, the resident was unaware of their care plan details and only knew about working with physical therapy. Interviews with facility staff revealed a lack of clarity and documentation regarding the provision of the baseline care plan to the resident. The social worker involved in the resident's admission process was unsure if a copy of the care plan was provided and did not document its provision. The Unit Manager confirmed that a baseline care plan should be completed within 48 hours and provided to the resident, but there was no documentation to support that this was done. The Director of Nursing reiterated the requirement for the baseline care plan to be developed and shared with the resident or their representative within the specified timeframe.
Medication Administration Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain professional standards of practice during medication administration for a resident with a wedge compression fracture and dementia. The surveyor observed that the medications administered to the resident did not match the physician's orders. Specifically, the resident was given High Potency Slow-Release Iron 45 mg instead of Ferrous Sulfate 325 mg, Fish Oil 1200 mg instead of Fish Oil 1000 mg, and Vitamin D3 25 mcg instead of Vitamin D3 125 mcg. These discrepancies were due to the unavailability of the correct medications in the medication cart. Interviews with Nurse #1, the Unit Manager, and the Director of Nurses confirmed that the medications administered were incorrect and constituted medication errors. Nurse #1 admitted to administering the available medications despite knowing they did not match the physician's orders. The Unit Manager and the Director of Nurses acknowledged that the facility should have the correct doses available or should order them if not in stock. A review of the medication storage room confirmed that the correct medications were not on hand.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate treatment and services for the care of an indwelling suprapubic cystostomy catheter for a resident. The deficiency was identified when the urinary collection bag of the resident was observed not being maintained below the level of the bladder, as required to prevent catheter-related urinary tract infections. Instead, the bag was improperly secured to the waistband of the resident's sweatpants and was also observed in contact with the floor without a barrier, exposing it to potential contaminants. The resident, who was cognitively intact and had a history of neuromuscular dysfunction of the bladder and spastic hemiplegic cerebral palsy, confirmed that the bag was not supposed to be positioned as observed. Interviews with the Director of Nursing, Nurse #4, and Unit Manager #1 revealed that the facility lacked a specific policy on Foley catheter care, and staff acknowledged the improper positioning of the urinary collection bag. They confirmed that the bag should be kept below the bladder level and not in contact with the floor to prevent infections and other complications. The resident had a history of frequent urinary tract infections, and the improper handling of the catheter bag increased the risk of further infections.
Deficiency in Respiratory Equipment Maintenance
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for a resident, leading to a deficiency. The resident, who was admitted in June 2024, had multiple diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, pulmonary hypertension, obstructive sleep apnea (OSA), and dependence on supplemental oxygen. The resident was cognitively intact and used a BiPAP machine at night and oxygen therapy during the day. Observations by the surveyor revealed that the BiPAP mask and tubing were not stored in a plastic bag when not in use, potentially exposing them to environmental contaminants. Additionally, the oxygen concentrator used by the resident was found to be covered in dust and debris, with the rear filter laden with dark brown matter. These conditions were observed on multiple occasions, indicating a lack of proper maintenance and storage of the respiratory equipment. Interviews with staff, including a nurse and the Director of Nursing (DON), confirmed that there were no specific orders or policies in place for cleaning the oxygen concentrator, changing the filter, or storing the BiPAP equipment. The staff acknowledged that the equipment should have been cleaned and stored properly, but there was uncertainty about the frequency and responsibility for these tasks. The DON admitted that there was no policy for the care and storage of respiratory equipment, and the expectation was for residents to have clean, safe, and operational respiratory equipment.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications. Specifically, the facility did not limit a PRN order for Ativan, an anti-anxiety medication, to 14 days as required by CMS guidelines. The resident, who was admitted with diagnoses including depression, dementia, and anxiety, was prescribed Ativan 0.5 mg as needed up to four times a day. The order was not given a specific stop date, and the medication was administered beyond the 14-day limit without documented rationale or reevaluation by the prescribing practitioner. The facility's policy on psychotropic medications requires that PRN orders be limited to 14 days unless a practitioner documents the rationale for extending the order and specifies a stop date. Despite this policy, the physician's orders for the resident's Ativan did not include a stop date, and the medication was administered multiple times beyond the initial 14-day period. The Consultant Pharmacist had recommended reviewing the PRN order and either discontinuing it or documenting the continued need with a specific stop date, but this recommendation was not adequately addressed. Interviews with facility staff, including nurses, unit managers, and the Director of Nursing, revealed a lack of clarity and adherence to the process for addressing pharmacy recommendations. The Director of Nursing was unable to locate documentation of the May recommendation, and staff interviews indicated that the process for ensuring compliance with the 14-day limit was not consistently followed. This oversight resulted in the resident receiving unnecessary medication without proper documentation or evaluation.
Failure to Obtain Level II PASARR for Transferred Resident
Penalty
Summary
The facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident who transferred to the facility in 2019. This resident, identified as having major depressive disorder, paranoid schizophrenia, and dementia with mood disturbances, was admitted without the necessary Level II PASARR documentation. The MassHealth Nursing Facility Bulletin 169 outlines that a Level II Evaluation is required for individuals with positive Level I Screenings to determine the appropriateness of nursing facility admission and the need for specialized services. Despite these requirements, the facility did not have the Level II PASARR in the resident's medical record. During interviews, the Director of Nursing (DON) acknowledged the absence of the Level II PASARR and indicated that the resident was a transfer from another facility. The DON admitted to not knowing if the resident required additional services for their mental illness and stated that they would contact the previous facility to locate the missing documentation. Further inquiry with the MassHealth PASARR office revealed no record of a Level II PASARR ever being completed for the resident, highlighting a lapse in the facility's compliance with PASARR requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 164 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Plymouth | 0.5 mi | ★★★★★ | 0 | 0 |
| Plymouth Rehabilitation & Health Care Center | 0.5 mi | ★★★★★ | 15 | 0 |
| Bay Path At Duxbury Nursing & Rehabilitation Ctr | 7.5 mi | ★★★★★ | 0 | 0 |
| Wingate At Silver Lake | 8.6 mi | ★★★★★ | 0 | 0 |
| Hannah B G Shaw Home | 12.6 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.