A list of the most recent deficiencies for Plymouth Health Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-10 | 2023-06-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-10 | 2023-06-02 | N |
| Provide appropriate foot care. | Health | 2023-05-10 | 2023-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-10 | 2023-06-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-06-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-10 | 2023-06-02 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-09 | 2023-06-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-09 | 2023-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-09 | 2023-06-02 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-03-29 | 2023-04-21 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-10 | 2022-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-10 | 2022-06-11 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-05-11 | 2022-06-03 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-11 | 2022-06-03 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-05-11 | 2022-06-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-11 | 2022-06-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-11 | 2022-06-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-11 | 2022-06-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-11 | 2022-06-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-11 | 2022-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-11 | 2022-06-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-05-11 | 2022-06-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-11 | 2022-06-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-11 | 2022-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-11 | 2022-06-03 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-05-11 | 2022-06-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-10 | 2022-06-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-10 | 2022-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-10 | 2022-06-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-10 | 2022-05-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-23 | 2021-10-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-23 | 2021-10-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-14 | 2021-10-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-14 | 2021-10-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-14 | 2021-10-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-14 | 2021-10-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-23 | 2021-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-23 | 2021-09-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-23 | 2021-09-23 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-08-23 | 2021-09-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-23 | 2021-09-23 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-05 | 2021-06-02 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-05 | 2021-06-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-05 | 2021-06-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-05 | 2021-06-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-05 | 2021-06-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-05-05 | 2021-06-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-05 | 2021-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-05 | 2021-06-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-05 | 2021-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-05 | 2021-06-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-05 | 2021-06-02 | N |
| Keep all essential equipment working safely. | Health | 2021-05-05 | 2021-06-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-04 | 2021-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-04 | 2021-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-04 | 2021-05-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-04 | 2021-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-04 | 2021-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-04 | 2021-05-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-04 | 2021-05-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-04 | 2021-05-06 | N |
