ElderGrade

Inspection citations at Plymouth Harborside Healthcare

58 citations on record, 9 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 13 1
2025 6 3
2024 14 0
2023 25 5
D February 13, 2026 Tag F0686 Corrected Mar 2026

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D February 13, 2026 Tag F0656 Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D February 13, 2026 Tag F0644 Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

D February 13, 2026 Tag F0585 Corrected Mar 2026

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

No actual harm, potential for more than minimal harm

D February 13, 2026 Tag F0554 Corrected Mar 2026

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

E February 13, 2026 Tag F0880 Corrected Mar 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E February 13, 2026 Tag F0848 Corrected Mar 2026

Administration Deficiencies

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

No actual harm, potential for more than minimal harm

E February 13, 2026 Tag F0847 Corrected Mar 2026

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

No actual harm, potential for more than minimal harm

E February 13, 2026 Tag F0812 Corrected Mar 2026

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E February 13, 2026 Tag F0699 Corrected Mar 2026

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

E February 13, 2026 Tag F0658 Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

F February 13, 2026 Tag F0867 Corrected Mar 2026

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

J February 13, 2026 Tag F0689 Corrected Mar 2026

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

E December 4, 2025 Tag F0689 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D September 16, 2025 Tag F0656 Complaint investigation Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D September 16, 2025 Tag F0609 Complaint investigation Corrected Oct 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

G September 16, 2025 Tag F0600 Complaint investigation Corrected Oct 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident

G August 5, 2025 Tag F0689 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

G August 5, 2025 Tag F0656 Complaint investigation Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Actual harm to a resident

B October 23, 2024 Tag F0645 Corrected Nov 2024

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, minimal potential

D October 23, 2024 Tag F0758 Corrected Nov 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 23, 2024 Tag F0695 Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D October 23, 2024 Tag F0690 Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D October 23, 2024 Tag F0658 Corrected Nov 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D October 23, 2024 Tag F0655 Corrected Nov 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0881 Corrected Nov 2024

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0880 Corrected Nov 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0812 Corrected Nov 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0759 Corrected Nov 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0699 Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0686 Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

E October 23, 2024 Tag F0684 Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

F October 23, 2024 Tag F0804 Corrected Nov 2024

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

G November 14, 2023 Tag F0689 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

G November 14, 2023 Tag F0656 Complaint investigation Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Actual harm to a resident

J October 11, 2023 Tag F0726 Complaint investigation Corrected Oct 2023

Nursing and Physician Services Deficiencies

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.

Immediate jeopardy to resident health or safety

J October 11, 2023 Tag F0678 Complaint investigation Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Immediate jeopardy to resident health or safety

B August 30, 2023 Tag F0641 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, minimal potential

D August 30, 2023 Tag F0883 Corrected Oct 2023

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

D August 30, 2023 Tag F0757 Corrected Oct 2023

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.