Plymouth Harborside Healthcare
PLYMOUTH HARBORSIDE HEALTHCARE in PLYMOUTH, MA — inspection on September 16, 2025.
Found 3 citations. 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
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Plymouth Harborside Healthcare
19 Obery Street Plymouth, MA 02360
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Plymouth Harborside Healthcare
19 Obery Street Plymouth, MA 02360
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: