Plymouth Harborside Healthcare

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Member #2 had called out for help, and a CNA (later identified as CNA #1) went to get Resident #2 out of Resident #3's bed.The Report further indicated Family Member #2 said that when CNA #1 woke Resident #2 up from sleeping, he/she displayed aggression and was combative with CNA #1.During an interview on 09/16/25 at 1:43 P.M., CNA #1 said that she has found Resident #2 in other residents' beds multiple times.

CNA #1 said that she has assisted with getting Resident #2 out of other resident's rooms, including Resident #1 and Resident #3's room. CNA #1 said Resident #2 has punched her and been combative towards her many times.During an interview on 09/16/25 at 11:03 A.M., Resident #3 said that there is an older resident (later identified as Resident #2) that comes into their room all the time. Resident #3 said that he/she will ask him/her to leave, but that staff usually have to escort him/her out of the room. Resident #3 said that Resident #2 has been found in his/her bed sleeping and said Resident #2 had hit him/her in the past.3) Review of the report submitted by the facility via the Health Care Facility Reporting System (HCFRS) Report, dated 08/25/25, indicated that at 5:15 P.M., yelling was heard coming from a resident's room (identified as Resident #4) and upon entering the room, Resident #4 was observed holding Resident #2's hands (trying to prevent Resident #2 from hitting him/her). The Report also indicated, that although unwitnessed, Resident #4 said that Resident #2 had grabbed his/her arm and punched him/her on his/her right arm and right cheek.Further review of the Report and Facility Investigative Findings indicated that Resident #4 told staff that Resident #2 had wandered into his/her room, picked up his/her lunch tray, removed some clothing from his/her bed and then Resident #2 laid down on his/her (Resident #4's) bed.Review of Resident #4's Behavior Health Group Note, dated 08/26/25, indicated that he/she spoke of

an incident involving Resident #2, and that Resident #4 said that he/she was shocked by the incident and said he/she has never been popped in the face before.Review of Resident #4's Behavior Health Group Note, dated 09/03/25, indicated he/she again discussed a recent incident where he/she alleged another resident (Resident #2) struck him/her in the face.During interviews throughout the day of the survey, dated 09/16/25, CNA s #1, #2, #4, #5, and #7 said they have witnessed and have been the recipient of Resident #2's aggressive and combative behaviors. All the CNA's said they were familiar with Resident #2's wandering behaviors and acknowledged that he/she requires supervision and constant redirection.During

an interview on 09/16/25 at 12:10 P.M., Nurse #1 said that she was aware that Resident #2 can be very aggressive and combative with staff. Nurse #1 said that she was also aware that Resident #2 wandered throughout the day into other residents' rooms and has a history of being combative with other residents.

During a telephone interview on 09/24/25 at 10:52 A.M., Nurse #2 said that she was aware that Resident #2 has been combative with staff and other residents.During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that Resident #2 was known to wander throughout the hallways of his/her unit and has been observed many times in multiple residents' rooms. Unit Manager #1 said that she was aware of Resident #2's aggressive and combative behavior towards staff and other residents. Unit Manager #1 said interventions such as magnetic stop signs and redirection were being implemented to decrease the risk for Resident #2 entering other residents' rooms. Unit Manager #1 said that the staff are aware of Resident #2's behaviors, and they continue to supervise and redirect Resident #2, as needed, when he/she was seen wandering around the unit.During an interview on 06/16/25, the Executive Director (ED) said that she was aware of Resident #2's behaviors, including his/her wandering and being combative with other residents and staff. The ED said that it is the Facility's expectation to maintain the safety of all residents, to accurately report and document behaviors for all residents and follow the plan of care for each resident to ensure a safe environment.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plymouth Harborside Healthcare

19 Obery Street Plymouth, MA 02360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

statement, then she did not have to.Nurse #2 said she did not know why an incident report wasn't completed and said she just followed what Unit Manager #2 told her and said she never asked CNA #4 for

a statement.During a telephone interview on 09/24/25 at 11:20 A.M., Unit Manager #2 said that he does not recall anyone reporting a resident to staff member altercation on 08/28/25.Unit Manager #2 said that if

a staff member had reported a resident to staff altercation, he was not certain that he would have initiated

an incident report. The Executive Director said that she was not made aware of the 08/28/25 incident involving Resident #2 and CNA #4. The Executive Director said that she does not know why they did not do

an incident report for either of these two incidents. The ED said that it was the Facility's expectation that all altercations that occur in the Facility be followed by an incident report and properly reported.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plymouth Harborside Healthcare

19 Obery Street Plymouth, MA 02360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for quite some time and that sometimes she finds it hanging on the side of the door and not properly attached.During an interview on 09/16/25 at 1:21 P.M., CNA #3 said that Resident #1 has had a stop sign at his/her door for about 6 months and said it is now broken and does not always stay in place properly,During an interview on 09/16/25 at 12 :10 P.M., Nurse #1 said that she does not know why Resident #1's stop sign was not across his/her doorway during surveyor observations.During an interview

on 09/16/25 at 2:04 P.M., Unit Manager #1 said that it was her responsibility to ensure each resident's care plan includes all identified interventions and goals. Unit Manager #1 said she thought she added the intervention of the stop sign to Resident #1's care plan. Unit Manager #1 said she did not know that Resident #1's stop sign was not being consistently utilized.2) Resident #4 was admitted to the Facility in March 2024, diagnoses include dementia with psychotic disturbances, major depression, and anxiety.Review of Resident #4's Physician's Orders, dated 09/16/25, indicated that his/her HCA had been invoked since 03/09/24.Review of the Health Care Facility Reporting System (HCFRS) Report, dated 08/25/25, indicated that at 5:15 P.M., a yell was heard coming from a resident's room (Resident #4) and upon entering the room, Resident #4 was observed holding Resident #2's hands (trying to prevent Resident #2 from hitting him/her). The Report further indicated that staff had provided a magnetic stop sign across Resident #4's doorway in hopes to deter Resident #2 from wandering into his/her room. Review of Resident #4's Care Plan titled Activities of Daily Living (ADL), dated as last revised 08/25/25, indicated that a magnetic stop sign was to be placed across his/her doorway as an intervention to maintain his/her safety.During multiple observations of Resident #4's room, on 09/16/25 throughout the day of the survey,

the Surveyor did not observe a magnetic stop sign across Resident #4's doorway at any time that day.Therefore, although Resident #4's care plan indicated he/she required the use of a magnetic stop sign across his/her doorway as an intervention to maintain his/her safety, based on the Surveyor observations

the intervention was not consistently implemented by staff.During an interview on 09/16/25 at 1:43 P.M., CNA #1 said she thinks that Resident #4 had a stop sign across his/her doorway but does not know what happened to it. During an interview on 09/16/25 at 1:21 P.M., CNA #3 said that Resident #4 has never had

a stop sign going across his/her doorway that she was aware of.During an interview on 09/16/25 at 12 :10 P.M., Nurse #1 said that she thought Resident #4's stop sign was to be placed across his/her doorway, only

a temporary intervention and does not know what happened to it. During multiple observations on Resident #2's unit, throughout the day of the survey, the Surveyor frequently observed Resident #2 wandering the unit without purpose or direction. During an interview on 09/16/25 at 2:04 P.M., Unit Manager #1 said that

she was aware that Resident #2 wandered around on the unit and that Resident #1 and Resident #4 were to have magnetic stop signs going across their doorways to help prevent Resident #2 from wandering into their rooms.During an interview on 09/16/25 at 2:57 P.M., the Executive Director said that she was not aware that Resident #1 and Resident #4's care plans were missing interventions or that interventions were not consistently being implemented and followed accordingly.The ED said that the Facility's expectation is that nurses are to develop care plans for all residents and the staff are to implement and follow interventions per the residents' care plan as indicated.

Event ID:

Facility ID:

If continuation sheet