The August 25 incident occurred when staff heard yelling from a room and found one resident trying to prevent another from striking them. The facility had installed magnetic stop signs across doorways specifically to prevent such encounters, but state inspectors discovered the barriers were consistently broken or missing.
Resident #1 had lived with a faulty stop sign for six months. The magnetic barrier was supposed to stretch across the doorway to deter a wandering resident from entering, but staff found it "hanging on the side of the door and not properly attached" rather than blocking access.
"It is now broken and does not always stay in place properly," CNA #3 told inspectors during interviews conducted September 16.
The wandering resident, identified as Resident #2, roamed the unit "without purpose or direction" throughout the day inspectors visited. Multiple staff members observed this behavior, yet the protective barriers remained ineffective.
Resident #4, who was involved in the August altercation, was supposed to have a magnetic stop sign installed after that incident. The facility's internal reporting system documented how staff "provided a magnetic stop sign across Resident #4's doorway in hopes to deter Resident #2 from wandering into his/her room."
But when inspectors arrived three weeks later, no stop sign existed.
"I think that Resident #4 had a stop sign across his/her doorway but does not know what happened to it," CNA #1 said during questioning.
Another aide contradicted this account entirely. CNA #3 told inspectors that "Resident #4 has never had a stop sign going across his/her doorway that she was aware of."
The confusion extended to nursing staff responsible for implementing care plans. Nurse #1 believed Resident #4's stop sign was only temporary and "does not know what happened to it."
Care plan documentation told a different story. Resident #4's plan, last revised August 25 following the incident, specifically required "a magnetic stop sign was to be placed across his/her doorway as an intervention to maintain his/her safety."
Unit Manager #1 acknowledged her responsibility for ensuring care plans included all necessary interventions. She told inspectors she thought she had added the stop sign requirement to Resident #1's care plan but "did not know that Resident #1's stop sign was not being consistently utilized."
The manager was aware that Resident #2 wandered the unit and that both Resident #1 and Resident #4 needed magnetic barriers "to help prevent Resident #2 from wandering into their rooms."
Resident #4 had been living at the facility since March 2024 with diagnoses including dementia with psychotic disturbances, major depression, and anxiety. A healthcare agent had been making decisions for the resident since March 9.
The facility's own reporting system captured the vulnerability these missing barriers created. The August incident report described how Resident #2 had gained access to Resident #4's room, leading to the physical confrontation that required intervention.
Executive Director said she was unaware that care plan interventions were missing or not being implemented consistently. She told inspectors the facility expected nurses to develop comprehensive care plans and staff to follow all interventions as indicated.
The breakdown occurred at multiple levels. Care plans existed requiring the safety barriers. Staff knew which residents needed protection from wandering. Managers understood their responsibilities for implementation.
Yet for months, the magnetic stop signs remained broken, missing, or improperly installed while a resident with dementia continued roaming the halls.
Nobody had ensured the simple intervention worked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plymouth Harborside Healthcare from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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