Inspection Reports for
Sunrise of Plymouth Beach

Emergency call response: In the months of November 2022, August 2023 and April 2024 there were over 476 e-call response times over the ten minutes required by Residence policy. Documentation of hourly safety checks for April 2024 had multiple instances where staff failed to document the hourly safety checks of the Special Care Residence residents during the hours of 7:00 p.m. and 7:00 a.m. (repeat finding).

Memory care unit: Safety issues identified in the Special Care Residence including secured entry and exit doors with a 15-second delayed opening not releasing when triggered. Documentation of physical/occupational therapist assessments every six months was incomplete for residents using bed rails or similar devices (repeat finding).

Resident screening and assessment · Resident care plans: The state cited these together under one finding. (repeat finding).

Quality assurance program: Missing or incomplete components of the Quality Assurance and Performance Improvement requirements including missing documentation of target dates, responsible staff, and clear outcomes for 2022 and 2023 calendar years. Medication Quality Plan reviews were insufficient in documenting and addressing reported medication errors in 2023 and 2024.

Incident reporting: The Residence filed 58 incident reports greater than 24 hours after the occurrence of the incident or accident.

Resident records: Inconsistent documentation of each 24-hour period over 90 days and inconsistent documentation of information necessary for the continuity of care. (repeat finding).

Staffing: Missing documentation of timely quarterly staffing level assessments for all four quarters of 2023 and the first quarter of 2024.

Staff health screening: Five records were missing documentation to confirm seasonal influenza vaccinations or declination statements.

Staff training: Missing documentation of general orientation, training needs assessments, personal care services provider training requirements, and biannual skills evaluations for personal care staff.