Plymouth Village: Fall Record Falsified for Dementia Resident - CA
Federal inspectors cited the Redlands nursing home following a complaint investigation completed May 28, 2026. The single violation involved one resident, identified in the report only as Resident 1. The harm was classified as minimal, but the mechanism of the failure was straightforward: a risk assessment designed to guide staff decisions about fall prevention contained information that was simply wrong.
Resident 1 came to Plymouth Village with a history of falling. Her admission records listed dementia, a history of falls, and a fracture of her left wrist as existing diagnoses. On April 4, 2026, she fell again. A Change in Condition Note from that date documented the fall. A Fall Risk Evaluation completed the same day noted she had experienced three or more falls in the past three months.
Then, on May 6, 2026, someone completed a new Fall Risk Evaluation. That form recorded "no falls in the past 3 months."
Resident 1 had fallen on April 4. She also fell on May 6, the same day the form was completed. The April fall, 32 days earlier, was not reflected anywhere on the updated assessment.
When inspectors reviewed the records with the Director of Nursing on May 26, the DON confirmed what the documents showed. The DON verified that Resident 1 had fallen on April 4, and that the May 6 evaluation had nonetheless been documented as showing no falls. "This was not accurately documented," the DON said.
The DON also confirmed that two facility policies had not been followed: one requiring staff to document any fall within the past 90 days in the medical record, and a general documentation policy requiring records to be objective, complete, and accurate. "Both policies were not followed," the DON said.
When inspectors visited Resident 1's room on May 18, she was sitting upright in bed, the bed lowered to its minimum height. She was wearing a cast on her left arm and a fall bracelet on her wrist. The bracelet is a standard alert used to flag residents at elevated fall risk. Her chart, at that point, still understated her fall history.
The practical consequence of inaccurate fall history is not abstract. A fall risk evaluation that omits recent falls can produce a lower risk score than the resident's actual history warrants. A lower score can mean fewer precautions. For a resident with dementia, who cannot reliably advocate for herself or report her own history, the accuracy of that record is not a formality. It is one of the primary ways the facility knows what she needs.
Resident 1 had already broken her wrist. She was already wearing a cast. She was already wearing a fall bracelet. The documentation failure did not occur in a vacuum of uneventful care. It occurred in the middle of an ongoing pattern of falls, to a resident who had already been seriously hurt.
The facility's falls protocol dated to March 2018. Its documentation policy dated to July 2017. Neither is new. The DON did not dispute that they applied or that they hadn't been followed.
Plymouth Village is a continuing care retirement community in Redlands. The inspection was triggered by a complaint. Inspectors reviewed three residents for fall-related documentation and found the problem in one.
Resident 1 sat in her room with a cast on her arm and a bracelet marking her as a fall risk while her chart recorded no recent falls. The bracelet told one story. The paperwork told another.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plymouth Village from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
PLYMOUTH VILLAGE in REDLANDS, CA was cited for violations during a health inspection on May 28, 2026.
Federal inspectors cited the Redlands nursing home following a complaint investigation completed May 28, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.