Resident #2 wandered into Resident #4's room on August 25, picked up his lunch tray, removed clothing from his bed, then laid down on it. When Resident #4 tried to stop him, Resident #2 grabbed his arm and punched him in the face and right arm.
Staff found Resident #4 holding Resident #2's hands, trying to prevent more hits, after hearing yelling from the room at 5:15 p.m.
"I was shocked by the incident and said I have never been popped in the face before," Resident #4 told behavioral health staff the next day. He brought up the assault again a week later during another group session.
The attack wasn't isolated. Resident #2 had been climbing into other patients' beds and hitting staff and residents for months while managers knew about the behavior but failed to stop it.
CNA #1 told inspectors she had found Resident #2 in other residents' beds "multiple times" and helped remove him from rooms belonging to Resident #1 and Resident #3. "Resident #2 has punched her and been combative towards her many times," according to the inspection report.
Resident #3 said the wandering resident "comes into their room all the time." Staff usually had to escort him out after Resident #3 asked him to leave. Resident #3 had found Resident #2 sleeping in his bed and said "Resident #2 had hit him/her in the past."
Five nursing assistants told inspectors they had witnessed or been victims of Resident #2's aggressive behavior. All acknowledged he required constant supervision and redirection because of his wandering.
The facility's own nurse was aware of the ongoing danger. Nurse #1 said she knew Resident #2 "can be very aggressive and combative with staff" and "wandered throughout the day into other residents' rooms and has a history of being combative with other residents."
Unit Manager #1 said Resident #2 was "known to wander throughout the hallways" and had been "observed many times in multiple residents' rooms." She knew about his "aggressive and combative behavior towards staff and other residents."
The manager said interventions like magnetic stop signs and redirection were being used to keep Resident #2 out of other rooms. Staff were supposed to supervise and redirect him when seen wandering.
Those interventions failed to prevent the August 25 assault on Resident #4.
Nurse #2 confirmed during a telephone interview that she was aware Resident #2 "has been combative with staff and other residents."
The Executive Director said she knew about Resident #2's wandering and combative behavior toward patients and staff. She said the facility's expectation was "to maintain the safety of all residents" and ensure a safe environment.
Yet Resident #2 continued entering other patients' rooms and attacking them.
Federal inspectors found the facility violated regulations requiring nursing homes to ensure each resident receives care in a safe setting and is free from abuse, neglect, exploitation, and injury. The violation was classified as causing actual harm to a few residents.
The pattern described in inspection records shows a facility that documented dangerous behavior but failed to implement effective interventions to protect vulnerable residents from a patient they knew posed a recurring threat.
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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