Plymouth Village
PLYMOUTH VILLAGE in REDLANDS, CA — inspection on May 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
in accordance with accepted professional standards.
observation, interview, and record review, the facility failed to ensure the clinical record contained
failure had the potential to result in an inaccurate assessment of fall risk and inappropriate fallˆprevention interventions, placing Resident 1 at increased risk for subsequent falls.During a review of Resident 1's clinical record, the admission Record (contains demographic and clinical data), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (memory loss beyond expected age and difficulty with thinking), history of falling, and unspecified fracture (break of the bone) of the lower end of the left radius (lower forearm) and left ulna (broken left wrist).During a review of Resident 1's Change in Condition Note, dated April 4, 2026, the Change in Condition Note indicated Resident 1 sustained a fall on April 4, 2026.During a review of Resident 1's Fall Risk Evaluation (a fall risk assessment is used to find out if you have a low, moderate, or high risk of falling), dated April 4, 2026, the Fall Risk Evaluation indicated Resident 1 had 3 or more falls in the past 3 months.During a record review of Resident 1's subsequent Fall Risk Evaluation, dated May 6, 2025, the Fall Risk Evaluation indicated, .no falls in the past 3 month., despite the documented fall on April 4, 2026, fall (32 days prior) and a fall on May 6, 2026.During an observation on May 18, 2026, at 2:53 PM in Resident 1's room, Resident 1 was sitting upright in bed, with the bed in the lowest position. A cast was on her left upper extremity and was wearing a fall bracelet on the wrist.During a concurrent telephone interview and record review on May 26, 2026, at 12:39 PM with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation, dated May 6, 2026, and Resident 1's Change in Condition Note, dated April 4, 2026, was reviewed.
The DON verified Resident 1 sustained a fall on April 4, 2026, but the Fall Risk Evaluation, dated May 6, 2026, was documented as having no falls in the past 3 months.
The DON stated this was not accurately documented.During a concurrent telephone interview and record review on May 26, 2026, at 12:41 PM with the DON, the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol, dated March 2018 was reviewed.
The P &P indicated, .The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days) .
The facility's P&P titled, Charting and Documentation, dated July 2017 was also reviewed.
The P &P indicated, .3.
Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
The DON stated both policies were not followed.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.