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 Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with a Stage 4 pressure ulcer on the left ischium/buttock did not receive the wound care ordered by the wound consultant. The consultant documented recurrent ulcer care with debridement and repeated orders for collagen dressing, alginate, and foam, then later changed the treatment to wound cleanser, Bactroban, alginate, and foam after odor and necrosis were noted. The record showed the facility instead used NS wash and alginate/foam or dry dressing, and the attending MD said she was not aware the consultant's recommendations were not being followed.
Medication Storage and Refrigeration Lapses: A nurse left a resident’s ophthalmic drops unattended on top of a med cart, multiple topical treatments and other meds were found left at the bedside in several resident rooms, and a med refrigerator was left open with refrigerated meds warm to the touch. Temperature logs also showed many missed checks, and staff stated these items should be secured and the refrigerator kept closed with temperatures documented each shift.
Uncovered Foley Drainage Bag Visible During Multiple Observations: A resident with urinary retention and an indwelling urinary catheter was repeatedly observed with the Foley drainage bag uncovered and visible while in bed, in a wheelchair, and ambulating in the hallway. The bag was seen lying on the floor beside the bed and hanging underneath the wheelchair without a privacy bag, with clear/yellow urine visible. An RN stated catheter bags should have privacy covers, and the DON said the resident was supposed to have one but staff forgot to put it on.
Failure to Follow Abuse Investigation and Reporting Procedures: A resident with dementia and cognitive communication deficit reported abuse concerns and asked to speak with police, but the DON treated the matter as a misunderstanding related to CNA positioning with pillows. The facility did not fully initiate its abuse investigation process, did not interview additional staff or residents beyond the CNA and roommate, and did not report the allegation to the state agency or police.
Failure to Report Allegation of Abuse: A resident with dementia, metabolic encephalopathy, and cognitive communication deficit told the surveyor there was abuse in the facility and wanted to speak with police. The DON was notified, but the allegation was not reported in HCFRS or to police after the DON determined it was a care concern rather than abuse; the investigation included limited interviews and did not involve broader staff or resident witness interviews.
Failure to Thoroughly Investigate an Abuse Allegation: A resident with dementia and cognitive communication deficit reported that there was "lots of abuse" in the facility and wanted to speak with police. The DON treated the concern as a grievance about a CNA’s use of pillows for positioning, but the investigation did not include broader staff or resident interviews, the CNA was not placed on admin leave, and the allegation and findings were not reported in HCFRS.
Medication, oxygen, and self-administration practices not followed: Staff did not consistently follow orders or nursing standards for several residents. One resident on dialysis missed scheduled antihypertensive doses without physician/NP notification, CNAs were observed adjusting portable O2 liter flow even though oxygen is treated as a medication and should be managed by licensed nurses, a resident’s scheduled lorazepam dose was signed out but not clearly given, and another resident was allowed to keep and apply Muscle Rub at the bedside without an order or self-administration assessment.
Medication Error Rate Exceeded 5% During Observed Pass: One nurse made 2 medication errors during an observed med pass, resulting in a 6.25% error rate. The nurse failed to give a resident ordered prednisolone eye drops after becoming distracted and administered buprenorphine-naloxone in film form instead of the ordered tablet form for another resident. The DON stated meds were expected to be given as ordered.
Food safety and sanitation standards were not followed in multiple nourishment areas and during meal service. Surveyors found dirty microwaves, unlabeled and undated food and beverages, expired milk, and residue in refrigerators, along with an opened nutritional shake and broth container lacking proper dating or resident identification. During lunch service, the FSD handled ready-to-eat food and other items with poor hand hygiene, reused a thermometer without cleaning it between checks, touched his face and clothing with gloved hands, and served ready-to-eat bread without a utensil.
A facility failed to maintain proper infection control for two residents with indwelling Foley catheters. One resident with urinary retention, UTI, and cognitive impairment was repeatedly observed carrying the catheter bag by hand or tube and leaving it on the floor while in bed or walking. Another cognitively intact resident with urinary retention was observed with the catheter bag lying on the floor in bed and dragging beneath a wheelchair. Staff confirmed the bags should have been secured and kept below the bladder, not on the floor.
Smoking Area Not Kept Clean or Maintained: Surveyors repeatedly observed cigarette butts scattered across the pavement, under chairs, and embedded in snow around the designated smoking area, with a black ash receptacle present but litter still accumulating. Staff said the usual smoking attendant had been absent for weeks, there was no cleaning schedule or assigned coverage, and residents often discarded cigarette butts on the ground instead of using the ash can.
The facility failed to provide a clean and homelike environment by not maintaining assistive devices for six residents. Observations showed issues like loose armrests and ripped seat backs on wheelchairs, and a resident had to tape their walker to prevent damage. Staff interviews revealed unclear processes for equipment maintenance, and the maintenance log lacked recent entries for the affected devices.
A facility failed to provide appropriate wound care for a resident with cysts on the elbow and thigh, as per the wound consultant's recommendations. Despite clear orders for specific dressings, treatments were not implemented, and medical records lacked documentation of necessary care. Miscommunication among staff led to the discontinuation of treatments, highlighting a lapse in adherence to professional standards and the resident's care plan.
A facility failed to provide necessary respiratory care for a resident by not administering oxygen at the correct flow rate, maintaining sanitary oxygen equipment, and ensuring a pulmonologist referral. The resident, with respiratory conditions, had orders for 2 L/min oxygen but was observed receiving 3-3.5 L/min. The BiPAP machine was not used as ordered, and no pulmonology appointment was scheduled, contributing to the deficiency.
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications by not attempting gradual dose reductions (GDRs). One resident on hospice services did not have a GDR attempted for antipsychotic medications despite no symptoms of psychosis. Another resident, cognitively intact and without behavioral changes, did not have a GDR attempted for olanzapine. A third resident on hospice, prescribed multiple psychotropic medications, also did not have a GDR attempted despite no behavioral issues. Staff interviews revealed a lack of awareness and evidence of GDR attempts.
The facility failed to maintain accurate medical records for four residents, as documentation of wound physician visits was not included in the medical records. A resident with traumatic brain injury and protein calorie malnutrition had missing wound physician notes, which were kept in the ICP's office. Another resident with a Stage IV pressure injury lacked documentation of wound physician visits for the past year. Additionally, a resident with large cysts and another with a pressure ulcer had missing wound care documentation in their medical records.
The facility failed to ensure consistent documentation of Advance Directives for two residents. One resident's physician's order did not match the court-ordered DNR/DNI status, while another resident's MOLST form was not reflected in the physician's orders, leading to discrepancies between the EHR and physical chart.
A resident developed an unstageable pressure ulcer, but the facility failed to notify the primary physician, leading to a delay in altering the treatment plan. The wound nurse did not document who was contacted, and the nurse practitioner and primary physician were unaware of the ulcer. The consultant wound physician's reports were sent to the wrong physician, resulting in a lack of proper documentation and awareness.
A facility failed to complete a required PASARR for a resident with bipolar disorder and alcohol abuse upon admission. The resident's medical records confirmed the active diagnosis, but no Level 1 PASARR was conducted by the facility. A social worker acknowledged the oversight, noting the only PASARR on record was from a previous facility in 2020.
A facility failed to develop and implement a care plan for a resident's BiPAP use, despite physician's orders and the resident's medical conditions requiring it. The resident, who was cognitively intact, reported not using the BiPAP machine, and a nurse confirmed the resident's refusal. The DON acknowledged the need for a care plan and documentation of the resident's refusal.
A facility failed to ensure proper care and treatment of a resident's PICC line, leading to a deficiency in IV fluid administration. The resident, with chronic osteomyelitis and Crohn's disease, required IV therapy for hydration. The facility did not obtain or implement physician's orders for PICC line care, including flushing, site assessment, and dressing changes. Observations revealed undated and improperly labeled IV equipment, and interviews confirmed inadequate documentation and adherence to policies.
A resident with chronic osteomyelitis and other conditions was incorrectly administered Fosfomycin daily instead of weekly due to an error in the Physician's Orders. The resident received the antibiotic daily for four days, contrary to the intended single weekly dose. The error was identified through a review of the Medication Administration Record, and interviews revealed a lapse in communication and verification of medication orders.
A resident with COPD and Diabetes was found to have unsecured medications, including Fluticasone nasal spray, a Trelegy inhaler, Calcium Carbonate tablets, and Diclofenac cream, on their overbed table. The resident self-administered these medications without an assessment for self-administration, and the DON was unaware of the unsecured medications, indicating a lapse in the facility's medication storage policy.
Failure to Follow Wound Care Orders for Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for one resident with a Stage 4 pressure ulcer on the left ischium/buttock. The resident was admitted with diagnoses including a Stage 4 pressure ulcer of the left buttock and was cognitively intact with a BIMS score of 15 out of 15. The facility policy stated that wound treatments are to be done per MD order. The Consultant Wound Care Provider documented that the wound appeared healed on 1/2/26 and then documented recurrence of the Stage 4 pressure ulcer on 1/9/26, with surgical debridement and an order for Prisma/Puracol/Dermacol or similar collagen dressing, alginate, and foam dressing changed daily and as needed. Similar recommendations were repeated on 1/16/26 and 1/23/26, with the wound showing granulation tissue and moderate serous drainage. On 1/30/26, the wound had decreased in size but had 30% yellow necrosis, odor, and mild periwound redness, and the Consultant Wound Care Provider changed the treatment to wound cleanser, Bactroban, alginate, and foam dressing. The medical record showed that from 1/3/26 through 1/30/26 the physician orders reflected normal saline wash, alginate, and foam or dry dressing, but did not reflect the collagen dressing recommended by the Consultant Wound Care Provider from 1/9/26 through 1/30/26. The record also failed to show implementation of the antibacterial wound cleanser and foam dressing after the 1/30/26 wound visit. The attending physician stated she was not aware the facility had not been following the Consultant Wound Care Provider's recommendations and said those recommendations should have been implemented, with disagreement documented if she had declined them.
Medication Storage and Refrigeration Lapses
Penalty
Summary
Medications and biologicals were not stored in accordance with accepted professional standards. On the [NAME] Unit, a nurse left Resident #50’s Prednisolone Acetate 1% and Timolol Maleate 0.5% ophthalmic drops on top of the medication cart while she walked away from the cart and out of view for about 30 minutes before returning them to the cart. The nurse stated she should have put the eye drops away before leaving, and the DON stated it was her expectation that medications not be left unattended on top of the medication cart. Multiple topical treatments and other medications were observed left at the bedside in 7 of 12 resident rooms on the Mayflower South unit. Items observed included Triad Hydrophilic wound dressing, Miconozole Nitrate 2% antifungal powder, polyethylene glycol 3350, Ventolin HFA inhaler, Muscle Rub, Flovent HFA inhaler, and fluticasone propionate nasal spray. Staff interviewed stated these medications and treatments should not be left at the bedside and should be secured. The medication refrigerator in one medication room was found open with an internal temperature of 70 degrees, and several refrigerated medications were warm to the touch, including Novolog, Lantus, Basaglar, Humalog, Lispro, Procrit, Desmopressin nasal spray, and Tubersol. Review of temperature logs showed multiple dates from August 2025 through January 2026 when the refrigerator temperature was not documented. Staff stated the refrigerator should be kept closed and temperatures checked and documented at least once per shift, and that medications not within storage temperature guidelines should be removed immediately.
Uncovered Foley Drainage Bag Visible During Multiple Observations
Penalty
Summary
The facility failed to ensure Resident #33 was treated with respect and dignity by not consistently covering the Foley catheter drainage bag with a privacy bag. Resident #33 was admitted in June 2025 with diagnoses including urinary retention and had an indwelling urinary catheter. The MDS dated 12/12/25 showed the resident was cognitively intact with a BIMS score of 15 out of 15 and had an indwelling urinary catheter. Physician orders included Foley catheter care every shift, catheter to bedside drainage bag while in bed every shift, and that a leg bag may be used. During multiple observations, the resident’s catheter drainage bag was seen uncovered and visible to others. On 1/27/26, the drainage bag was lying directly on the floor beside the bed, visible from the doorway, and not covered by a privacy bag. On 1/28/26, the bag was observed uncovered while the resident was in a wheelchair in the hallway, seated at the bedside, and later in the room watching television, with clear/yellow urine visible from the doorway. On 1/29/26, the resident was observed ambulating in the hallway with therapy staff, and the Foley catheter bag was again not covered by a privacy bag and visible to anyone in the hallway. Nurse #7 stated that the resident and all residents with catheter bags should have privacy bags, and the DON stated the resident was supposed to have a privacy cover on the catheter bag and staff must have forgotten to put it on.
Failure to Follow Abuse Investigation and Reporting Procedures
Penalty
Summary
The facility failed to implement its written abuse, neglect, and exploitation policies and procedures after an allegation of potential abuse was reported during the survey for one resident. The facility’s policy required immediate investigation of alleged violations, identification and interviewing of involved persons and witnesses, protection of the resident during the investigation, and reporting of allegations and investigative findings within required timeframes. The report states the facility did not initiate its abuse policy after the allegation was brought to the surveyor’s attention. Resident #18 was admitted in August 2025 with diagnoses including metabolic encephalopathy, dementia, and cognitive communication deficit. The resident’s MDS dated 1/23/26 indicated cognitive intactness with a BIMS score of 13 out of 15 and dependence on staff for activities of daily living. During an interview on 1/28/26, the resident stated there was lots of abuse in the facility, that staff thought he/she was crazy, and that he/she wanted to speak with the police, but did not want to share more with the surveyor. After the surveyor notified the DON of the resident’s report, the DON completed a grievance form and determined the concern involved the CNA’s method of positioning the resident with pillows and a bad attitude. The DON and ADON documented the resident’s preference not to receive care from that CNA, and the CNA provided a written statement. The DON and Administrator stated they viewed the matter as a misunderstanding or care concern rather than abuse, and the DON said no report was made to the state agency or police, no other staff or residents on the unit were interviewed beyond the CNA and roommate, and the resident’s health care proxy was not informed.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report a potential allegation of abuse for one resident, despite its policy requiring alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within the required timeframe. Resident #18 was admitted with diagnoses including metabolic encephalopathy, dementia, and cognitive communication deficit, and the resident’s MDS assessment dated 1/23/26 indicated cognitive intactness with a BIMS score of 13 out of 15 and dependence on staff for activities of daily living. During an interview on 1/28/26 at 12:06 P.M., the resident stated there was lots of abuse in the facility, that staff thought he/she was crazy, and that he/she was not comfortable sharing further because he/she did not know the surveyor; the resident also said he/she had not told facility staff but wanted to speak with the police. The surveyor notified the DON of the resident’s report of abuse and request to speak with police on 1/28/26 at 12:08 P.M. Review of the HCFRS on 1/29/26 did not show that the facility submitted a report for the allegation. The Administrator stated the DON completed an investigation within two hours and determined it was not necessarily abuse but more of an educational opportunity for the CNA, and therefore it was not reported in HCFRS. The DON stated she would normally interview the resident, staff, and any witnesses to determine whether abuse occurred, but in this case the ADON only spoke with the resident’s roommate and no other residents on the unit or staff were interviewed beyond CNA #9, who had been caring for the resident when the allegation was reported. The DON later stated she determined the concern was a care concern, not abuse, so she did not report the allegation in HCFRS or notify the police.
Failure to Thoroughly Investigate an Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and cognitive communication deficit, and the most recent MDS indicated the resident was cognitively intact with a BIMS score of 13 out of 15 and dependent on staff for activities of daily living. During an interview, the resident stated there was "lots of abuse" in the facility and that staff thought the resident was crazy, but did not want to share further details with the surveyor and wanted to speak with police. After the surveyor notified the DON of the resident’s report, the DON completed a grievance form and determined the concern was related to the CNA’s method of positioning the resident with pillows. The grievance documentation stated the resident did not like having pillows behind the back for positioning and said the CNA would not remove them and had a bad attitude. The DON also documented that the resident preferred the CNA not provide care going forward, and the CNA was educated on refusal of care, customer service, and resident rights. The grievance form did not include the abuse allegation reported to the DON by the surveyor. The investigation did not include interviews with other staff or residents on the unit beyond the CNA and the resident’s roommate, and the CNA was not placed on administrative leave during the investigation. The facility did not report any allegation of abuse involving the resident or the investigation findings in HCFRS by survey exit. The DON later stated she considered the concern a care issue rather than abuse and did not notify the police or the resident’s health care proxy.
Medication, oxygen, and self-administration practices not followed
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of practice for four sampled residents. The deficiencies involved medication administration, oxygen management, and self-administration of a topical treatment. The report included interviews, record review, and direct observation showing that staff actions and omissions did not align with physician orders, facility policy, or nursing practice standards. For one resident with ESRD, hypertension urgency, and dialysis treatment, the physician ordered Labetalol 300 mg every 8 hours with a hold parameter for SBP less than 130. The MAR showed the 2:00 P.M. dose was repeatedly marked not given on dialysis days, and the record did not show that the physician or NP was notified of the missed doses. Nurses stated they held the medication when the resident was at dialysis and did not send medications to dialysis or report the missed doses. The DON stated the medication should have been scheduled around the times the resident was in the facility and that several missed doses should have been relayed to the physician or NP. For another resident with COPD and chronic respiratory failure, the surveyor observed a CNA manipulating the liter flow on a portable oxygen tank after the resident stated no oxygen was flowing. The CNA said she could fill portable oxygen tanks and turn them on, and another CNA was observed turning on a portable oxygen tank for the resident. A nurse stated CNAs were allowed to fill portable oxygen tanks but were not allowed to manipulate the liter flow, while another nurse stated CNAs were allowed to fill oxygen tanks and adjust the liter flow. The SDC stated oxygen is considered a medication and only licensed nurses can administer and manipulate the liter flow with a physician's order, and the DON stated CNAs should not be adjusting or turning on oxygen tanks. For a resident receiving scheduled Lorazepam for anxiety, the narcotic count was off by one tablet during a count with the surveyor and the nurse who had administered the morning dose. The nurse stated she was certain she gave the dose but then said, based on the remaining tablets, she was unsure whether the resident actually received the ordered medication. The incident report identified that the nurse signed one tablet out of the narcotic log without giving the medication and that the resident was unaware. For another resident who had pain, osteoarthritis, and muscle weakness, the surveyor observed a tube of Muscle Rub at the bedside and observed the resident applying it independently. The record did not contain an order for self-administration or bedside storage, and self-administration assessments indicated the resident did not want to self-administer medications and had not been assessed to do so.
Medication Error Rate Exceeded 5% During Observed Pass
Penalty
Summary
The facility failed to remain free from a medication error rate of 5% or greater when one nurse observed during a medication pass made 2 errors out of 32 opportunities, resulting in a 6.25% medication error rate. The errors affected two residents out of three residents observed. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice stated that licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. For one resident, the physician's order was for Prednisolone Acetate Ophthalmic Suspension 1% to be instilled as 1 drop in both eyes two times a day, but the nurse prepared the resident's morning medications, returned the eye drops to the cart, and began preparing medications for another resident without administering the ordered eye drops. During interview, the nurse stated she became distracted after administering the resident's inhaler and forgot the eye drops. For another resident, the physician's order was for Buprenorphine HCl-Naloxone HCl 8-2 mg sublingual tablet three times a day, but the nurse administered the sublingual film form instead of the tablet form listed in the order. The DON stated it was her expectation that medications were administered as indicated by the physician's orders.
Food Safety and Hand Hygiene Lapses in Nourishment Areas and During Meal Service
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in three of four nourishment kitchenettes. Surveyors observed brown/orange food splatter and residue inside microwaves in the Hopkins Unit, Mayflower Unit, and another unit. In the Hopkins Unit freezer, a Lean Cuisine frozen dinner had a manufacturer expiration date of August 2026 but no resident identification. In the Mayflower Unit refrigerator, an opened 2-liter bottle of Diet Coca Cola and an opened 20-ounce bottle of ginger ale had no resident identification, and a white takeaway container with an illegible resident name and a date of 12/2025 contained mashed potatoes with gravy and ground meat with gravy and crust; water droplets were noted inside the container. In the third nourishment kitchenette, an opened Vanilla Med Pass 2.0+ fortified nutritional shake was undated, although the manufacturer label indicated it should be discarded four days after opening if properly refrigerated. An opened spicy chicken broth container had no resident identification and was undated. Multiple milk cartons were found past their manufacturer expiration dates, including whole milk cartons dated 1/26/26 and 1/28/26 and fat-free milk cartons dated 1/28/26. Two energy drink cans had no resident identification, and residue with hair was observed underneath the bottom drawers of the refrigerator. The microwave in this kitchenette had brown/orange food splatter and residue, and the white inner plastic component was peeling with exposure of metal components on the top and bottom. During lunch line service, the Food Service Director handled food and equipment in ways that did not follow hand hygiene and cross-contamination standards. After washing his hands, he wiped a thermometer with the same paper towel used to dry his hands, used a dirty/stained potholder while placing breaded fish into a pan, touched broccoli with an ungloved hand, and used the thermometer repeatedly without cleaning it between temperature checks. He also removed gloves and put on new gloves without hand hygiene, touched paper, his apron, pants, and face/nose with gloved hands, and continued plating food without changing gloves or washing hands. He served ready-to-eat bread with a gloved hand rather than using a utensil. The Food Service Director and Administrator both acknowledged that the thermometer should be cleaned between uses and that gloves and hand hygiene should have been changed or performed as needed.
Foley Catheter Bags Left on Floor and Not Secured
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents with indwelling Foley catheters. Resident #13 had diagnoses including urinary retention and urinary tract infection, and records showed orders for Foley catheter care, catheter replacement, and enhanced barrier precautions. The resident also had cognitive impairment, with a BIMS score of 5 out of 15, and was observed multiple times handling the catheter bag while walking or in bed, with the bag not secured and lying directly on the floor without a protective barrier. For Resident #13, surveyors observed the Foley drainage bag being carried by the bag or drainage tube, placed on the floor beside the bed, and left on the floor while the resident was in bed or moving around. Staff interviews confirmed that the resident sometimes put the catheter on the bedside table or floor and picked it up independently, and that the resident required constant reminders to keep the catheter off the floor. The Infection Control Nurse and DON stated that Foley catheter bags should not be on the floor and should be secured properly below the level of the bladder. Resident #33 had diagnoses including urinary retention and was cognitively intact with a BIMS score of 15 out of 15. Physician orders included Foley catheter care, flushing, and use of a leg bag if needed. Surveyors observed the Foley catheter bag lying on the floor while the resident sat in bed, and later hanging underneath a wheelchair and dragging on the floor during transport and while seated in the wheelchair. Staff interviews confirmed the bag should have been secured to the bedframe or wheelchair and not allowed to lie on the floor, and the DON stated the catheter bag was supposed to be secured and not allowed to lie directly on the floor.
Smoking Area Not Kept Clean or Properly Maintained
Penalty
Summary
The nursing home failed to ensure the designated smoking area was kept safe, clean, and properly maintained, as cigarette butts were repeatedly observed scattered across the pavement and embedded in snow around the smoking area. Survey observations on multiple occasions identified a tall black receptacle for cigarette butts with numerous cigarette butts on the ground, cigarette butts protruding from the adjacent snowbank, and cigarette butts accumulated underneath several chairs positioned around the perimeter of the area. The usual smoking area had been temporarily moved to the front of the building due to snow. Staff interviews confirmed that the smoking area was not being consistently maintained because the facility was without a smoking attendant for about three weeks. A CNA stated the smoking assistant normally cleaned the area after each smoke, but there was no one assigned at the time, and residents often threw cigarette butts on the ground instead of using the ash can. The Maintenance Director said the smoking attendant would clean the area, but there was no cleaning schedule or assigned staff to maintain the area in the attendant's absence. The Administrator stated maintenance and housekeeping usually maintained the area, smoking attendants emptied ashtrays and cleaned up, and the facility was down a full-time smoking attendant, but she was not sure why the area had not been maintained.
Facility Fails to Maintain Clean and Functional Assistive Devices
Penalty
Summary
The facility failed to maintain a clean and homelike environment for six residents on the [NAME] Unit by not providing properly maintained assistive devices such as wheelchairs and walkers. Observations revealed that several wheelchairs had issues such as loose armrests, ripped seat backs, and missing or damaged padding, which were not addressed in a timely manner. For instance, one resident's rolling walker had a cracked arm pad that was taped together, and another resident's wheelchair was labeled with a discharged resident's name, indicating a lack of proper maintenance and oversight. Interviews with staff and residents highlighted a lack of awareness and unclear processes regarding the maintenance and repair of assistive devices. A resident mentioned having to tape their walker to prevent further damage, while a nurse admitted to not knowing the procedure for routine repairs. Additionally, the maintenance log did not reflect any recent entries for the affected residents' equipment, suggesting a gap in the facility's system for tracking and addressing equipment issues. The Rehab Staff acknowledged the oversight and emphasized the need for immediate repair or replacement of the damaged equipment.
Failure to Implement Wound Care Treatments
Penalty
Summary
The facility failed to provide appropriate wound care treatment for a resident, as per the recommendations of the wound consultant physician and the primary physician's treatment plan. The resident, who was cognitively intact, had a large cyst on the right elbow and thigh, which required specific wound care treatments. Despite the presence of clear orders from the consultant wound physician to apply specific dressings to the cysts, these treatments were not implemented as prescribed. The resident's medical records indicated a lack of documentation for the required treatments and monitoring of the cysts. The Treatment Administration Record showed that the prescribed treatments were not consistently followed, and there were no records of the necessary dressings being applied to the resident's wounds. Interviews with the nursing staff revealed a miscommunication regarding the implementation of the treatment orders, leading to the discontinuation of necessary care for the resident's wounds. The Assistant Director of Nurses and the Wound Nurse acknowledged the failure to implement the recommended treatments and the absence of weekly evaluations for the resident's wounds. The discontinuation of the treatment for the right elbow and the lack of implementation of the new treatment for the right thigh were attributed to miscommunication and oversight. This deficiency highlights a significant lapse in the facility's adherence to professional standards of practice and the resident's care plan.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident, specifically in administering oxygen at the correct liter flow as per physician's orders, maintaining oxygen equipment in a sanitary manner, and ensuring the resident was referred to a pulmonologist. The resident, who was admitted with chronic obstructive pulmonary disease, pneumonia, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea, had a physician's order for continuous oxygen via nasal cannula at 2 liters per minute. However, observations revealed that the oxygen concentrator was set at 3 to 3.5 liters per minute, contrary to the physician's order. The resident's care plan included interventions for respiratory disease, such as assisting with repositioning for maximum airflow and monitoring oxygen saturation levels. Despite these interventions, the resident's oxygen tubing was not changed as frequently as ordered, and the BiPAP machine, which was supposed to be used at night, was not utilized by the resident. Interviews with nursing staff indicated a lack of adherence to the physician's orders, with discrepancies in the oxygen flow rate and the resident's refusal to use the BiPAP machine. Additionally, the facility did not schedule a pulmonology appointment for the resident, as indicated in the hospital discharge summary. The Director of Nursing confirmed that there was no documentation of a pulmonologist referral, which was necessary for the resident's ongoing respiratory care. This lack of follow-up and adherence to physician's orders contributed to the deficiency in providing appropriate respiratory care for the resident.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications. For Resident #1, the facility did not attempt a gradual dose reduction (GDR) of the antipsychotic medications risperidone and chlorpromazine, despite the resident being on hospice services and not exhibiting symptoms of psychosis. The Director of Nurses (DON) admitted that GDRs were not previously being attempted for residents on antipsychotic medication, and there was no evidence that a GDR was discussed or attempted for this resident in the past year. Resident #123 was admitted with diagnoses including visual hallucinations and dementia. Despite being cognitively intact and not exhibiting any signs of delirium or behavioral changes, the facility failed to attempt a GDR of the antipsychotic medication olanzapine since the resident's admission. Interviews with staff revealed uncertainty about the review or attempt of GDRs, and the DON confirmed that no evidence of a GDR attempt was available for this resident. Resident #87, who was on hospice services, was prescribed multiple psychotropic medications, including olanzapine and sertraline. Despite the resident not exhibiting any behaviors or changes in mood, the facility did not attempt a GDR in the previous 12 months. Observations noted the resident often sitting with their head on the table, and interviews with staff and family indicated a lack of awareness regarding the need for GDRs. The DON acknowledged that the resident had not been discussed at interdisciplinary team meetings for GDRs.
Failure to Maintain Accurate Medical Records for Wound Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for four residents. Specifically, the documentation of wound physician visits was not included in the medical records in a timely manner. For Resident #58, who was admitted with diagnoses including traumatic brain injury and protein calorie malnutrition, the wound physician's notes were not found in the medical record. Instead, they were kept in a folder in the Infection Control Preventionist's (ICP) office, which was confirmed during an interview with the ICP. Resident #92, admitted in April 2021, had a Stage IV pressure injury and required specific wound care treatments. However, the medical record did not include any documentation of visits from the consultant wound physician for the past year. The Assistant Director of Nurses (ADON) confirmed that the wound physician's visit paperwork was kept in the ICP's office and not included in the resident's medical record. Similarly, Resident #79, admitted in October 2024, had large cysts on the right upper and lower extremities, but the medical record lacked documentation of current treatments or monitoring. The wound physician's visit notes were also missing from the medical record. Resident #90, who developed a pressure ulcer, had wound consultant visits documented in the ICP's office but not in the medical record. The ICP believed the consultant wound physician was uploading the visit summaries to the electronic medical record, but this was not the case.
Inconsistent Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that the medical orders for Advance Directives were consistent with the court-ordered directives for two residents. For Resident #1, there was a discrepancy between the physician's order and the medical record regarding the resident's code status. Although the court had authorized the guardian to consent to a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, the physician's order indicated a full code status. Interviews with staff revealed that the information in the electronic health record (EHR) and the physical chart did not match, leading to confusion about the resident's actual code status. Similarly, for Resident #123, the facility did not update the physician's orders to reflect the resident's executed Advance Directives as indicated on the Massachusetts Order for Life Sustaining Treatment (MOLST) form. The MOLST form showed a DNR/DNI status, but the physician's orders incorrectly indicated a full code status. Staff interviews confirmed that the discrepancy between the physical chart and the EHR could lead to confusion during emergencies, as the orders did not accurately reflect the resident's current code status.
Failure to Notify Physician of Pressure Ulcer
Penalty
Summary
The facility failed to notify the primary physician about a new pressure ulcer on a resident, which was necessary to alter the treatment plan and prevent further deterioration. The resident, who was at risk for skin integrity issues due to conditions such as diabetes, developed an unstageable pressure ulcer on the coccyx. The initial treatment with triad paste was continued without proper documentation of physician verification. The wound nurse was unable to recall or document who was contacted regarding the ulcer, and the physician's orders were not updated until several days later. The resident's medical record did not include documentation from the consultant wound physician, and the primary physician and nurse practitioner were unaware of the pressure ulcer. The nurse practitioner, who was responsible for interim needs, discovered that staff were initiating treatment orders without physician verification. Additionally, the consultant wound physician's visit summaries were sent to the previous primary physician, not the current one, leading to a lack of awareness and documentation of the pressure ulcer by the responsible medical staff.
Failure to Complete PASARR for Resident with Mental Condition
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosed mental condition. The resident, admitted in January 2024, had diagnoses including bipolar disorder and alcohol abuse. A review of the resident's medical records, including a Psychiatric Evaluation and Consultation and a Minimum Data Set (MDS) assessment, confirmed the presence of bipolar disorder as an active diagnosis. However, the medical record did not indicate that a Level 1 PASARR was completed upon the resident's admission to the facility. During an interview, a social worker confirmed that the facility's social workers are responsible for completing the PASARR at the time of admission and acknowledged that the only PASARR in the record was from 2020, completed by another facility. The social worker also verified with the PASARR agency that no Level 1 PASARR was completed for the resident upon admission to the current facility.
Failure to Develop and Implement Care Plan for BiPAP Use
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident who required the use of a BiPAP machine. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, pneumonia, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea, was cognitively intact and had physician's orders for BiPAP use at bedtime. Despite these orders, the resident's care plan did not include any information regarding the use of the BiPAP machine. The deficiency was identified through observation, interview, and record review. The resident reported not using the BiPAP machine after their last hospitalization, and a nurse confirmed that the resident should be using the machine at night but had refused. The Director of Nursing acknowledged that a care plan should have been developed and implemented for the resident's BiPAP use, and that any refusal by the resident should be documented in their record and care planned.
Deficiency in PICC Line Care and Maintenance
Penalty
Summary
The facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in the administration of intravenous (IV) fluids. The resident, who was admitted with chronic osteomyelitis, resistance to Vancomycin, ESBL resistance, and Crohn's disease with fistulas, required IV therapy for hydration due to a high-output ostomy. Despite the critical need for IV therapy, the facility did not obtain or implement physician's orders for the care and maintenance of the resident's PICC line, including necessary procedures such as IV flushing, site assessment, dressing changes, catheter measurement, and arm circumference measurement. The facility's policies required specific orders for vascular access device flushing and detailed procedures for needleless connector changes, catheter dressing changes, and continuous medication administration. However, the resident's records lacked documentation of these essential care and maintenance activities. The Infusion Therapy Flowsheet was incomplete, with missing information on catheter length, arm circumference, and dressing changes. Additionally, there was no documentation of needleless connector changes, and the tubing change schedule was not adhered to, with several instances of missing site assessments. Observations by the surveyor revealed that the resident's PICC line dressing was undated and slightly lifted, and the IV bag and tubing were not labeled with a date and time. Interviews with nursing staff and the Director of Nursing confirmed the absence of proper documentation and adherence to facility policies. The Director of Nursing acknowledged that the resident's PICC information should have been included in the record and that nurses should have documented dressing changes, external catheter length, arm circumference, and needleless connector changes weekly.
Medication Administration Error: Fosfomycin Dosage Frequency
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Fosfomycin. The resident, who was admitted with chronic osteomyelitis, resistance to Vancomycin, ESBL resistance, and Crohn's disease with fistulas, was prescribed Fosfomycin as a prophylactic measure following a urinary tract infection. The After Visit Summary indicated that the resident should take Fosfomycin as a single dose, but the Physician's Orders mistakenly prescribed it as a daily dose. Consequently, the resident received Fosfomycin daily for four days instead of the intended single weekly dose. The error was identified during a review of the Medication Administration Record, which showed daily administration of Fosfomycin. Interviews with the Director of Nursing and the physician revealed that the order was entered incorrectly, and the physician was unavailable to verify the correct dosage frequency due to being on vacation. The physician later confirmed that Fosfomycin is typically dosed weekly, not daily, indicating a lapse in communication and verification of medication orders upon the resident's return from the hospital.
Unsecured Medications Found in Resident's Room
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely in accordance with professional principles. Specifically, for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Diabetes, medications including Fluticasone nasal spray, a Trelegy inhaler, Calcium Carbonate chewable tablets, and Diclofenac cream were found unsecured on the resident's overbed table. These observations were made on two separate occasions by the surveyor, indicating a lapse in adherence to the facility's medication storage policy. Interviews revealed that the resident self-administered these medications and refused to allow staff to remove them from the room. Nurse #1 acknowledged awareness of the situation but noted that the resident had not been assessed for self-administration of medications. The Director of Nursing was unaware of the unsecured medications, highlighting a communication gap and oversight in ensuring compliance with the facility's policy, which mandates that medications be stored in a locked cart or room accessible only to licensed nursing personnel.
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.
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What surveyors actually found near you
We read the 169 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 | 0.4 mi | ★★★★★ | 0 | 0 |
| Plymouth Harborside Healthcare | 0.5 mi | ★★★★★ | 17 | 1 |
| Bay Path At Duxbury Nursing & Rehabilitation Ctr | 7.3 mi | ★★★★★ | 0 | 0 |
| Wingate At Silver Lake | 8.2 mi | ★★★★★ | 0 | 0 |
| Hannah B G Shaw Home | 12.1 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.