Plainfield Health Care Center

Inspectors wroteBased on record review and interview, the facility failed to protect a resident's psycho-social well-being by not addressing trauma related triggers for a resident with post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event) for 1 of 1 resident reviewed for PTSD (Resident B).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure vital sign equipment was cleaned, hand hygiene was completed between residents, and enhanced barrier precautions (EBP) (infection control practices designed to prevent the spread of multidrug-resistant organisms in nursing homes) during a medication pass observation (Residents S, T, and U).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were knowledgeable of the dishwasher rinse temperature required for sanitization during 1 of 1 dishwasher observation. This deficient practice had the potential to affect 101 residents who received meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to develop and maintain a comprehensive, facility-specific assessment that accurately identified and documented the staffing resources necessary to care for its resident population, including the specific number and ratio of staff required to meet resident needs. This deficient practice had the potential to affect 103 of 103 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident specific dementia care plans were developed and utilized prior to psychotropic medications being initiated or increased for 4 of 5 residents reviewed for dementia (Residents 19, 76, 7, and 11).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative was notified of new medication orders for 1 of 6 residents reviewed for unnecessary medications (Resident 19), and the facility failed to ensure informed consent was obtained prior to the initiation or increase of psychotropic medications for 3 of 6 residents reviewed for unnecessary medications (Residents 19, 76, and 7).

Inspectors wroteBased on record review and interview, the facility failed to code the Minimum Data Set (MDS) accurately for 2 of 8 residents reviewed for MDS accuracy (Resident 2 and 81).

Inspectors wroteBased on record review and interview, the facility failed to submit a new level one Pre-admission Screening and Resident Review (PASRR) (a federally mandated process to prevent inappropriate placements of individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [I/DD] into Medicaid-certified nursing facilities) when new SMI were added for a resident for 1 of 7 residents reviewed for PASRR compliance (Resident 12).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's risk for pressure ulcers (localized damage to the skin and underlying soft tissue from prolonged pressure) was addressed for a resident who developed pressure ulcers and failed to ensure the resident's low air loss mattress (specialized mattress) was set appropriately for 1 of 4 residents reviewed for pressure ulcers (Resident 9).

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide nephrostomy (a procedure where a thin, flexible tube is inserted through the skin of your lower back directly into the kidney to drain urine) monitoring and care for a resident with tubes for 1 of 1 resident reviewed for nephrostomy tubes (Resident 8).

Inspectors wroteBased on record review and interview the facility failed to ensure pharmacy recommendations were appropriately reviewed and addressed timely by a medical professional for 2 of 5 Residents (Resident 11 and 81) reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility failed to identify and provide wound care services by ensuring wound assessments and treatments were provided to prevent worsening wounds for 1 of 3 residents reviewed for wound care (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to ensure documentation of assessment and treatment progress of pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged pressure, shear, or friction) were completed for 1 of 3 residents reviewed for wounds (Resident C).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and interventions for an aggressive dementia resident (Resident L) on the locked dementia unit resulting in the resident forcibly removing another resident (Resident N) out of her wheelchair causing bruising to her eye and nose. This deficiency had the ability to affect 21 of the 21 residents residing on the locked dementia unit. The immediate jeopardy began on 12/30/25 when Resident L wanted Resident N's wheelchair and forcibly removed her from the wheelchair resulting in bruising and swelling to Resident N's right eye and nose. Resident L had previously wandered into another resident's room and punched a staff member when they attempted to re-direct him on 12/12/25. On 1/8/26 the Nurse Practitioner documented that Resident L was a risk to himself and others. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the physician or family following identifying an injury of unknown origin for 1 of 4 residents reviewed for accidents (Resident M).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to implement policies and procedures to immediately report an injury of unknown origin to the Administrator or Director of Nursing for 1 of 11 residents reviewed for abuse and neglect (Residents M).

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate an injury of unknown origin following observation of a resident with swelling and discoloration of his left eye for 1 of 11 residents reviewed for abuse and neglect (Resident M).

Inspectors wroteA. Based on record review and interview, the facility failed to follow physician ordered parameters regarding medication administration of blood pressure medication for 2 of 11 residents reviewed for abuse and neglect (Residents E and L). B. Based on observation, interview, and record review, the facility failed to perform assessments following observation of a resident with swelling and discoloration of his left eye for 1 of 11 residents reviewed for abuse and neglect (Resident M).

Inspectors wroteBased on record review and interview, the facility failed to complete an Interdisciplinary Team (IDT) post fall assessment and implement post fall interventions for 3 of 3 residents reviewed for accidents. (Resident B, E, and F)

Inspectors wroteBased on record review and interview, the facility failed to complete physician ordered weekly skin assessments or document the resident's refusal for 2 of 4 residents reviewed for quality of care. (Resident B and E)

Inspectors wroteBased on interview and record review, the facility failed to contact the physician for blood sugar values outside the ordered parameters for 1 of 4 residents reviewed for quality of care (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to complete ordered skin assessments for 1 of 4 residents reviewed for quality of care (Resident D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sufficient amount of staff to provide nursing activities of daily living (ADL) care and laundry services so that residents received ADL care and did not have to wait a long time for assistance. This deficient practice had the potential to effect 114 of 114 residents who received nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' grievances had follow ups that provided adequate/effective interventions to address and prevent reoccurring concerns related to staff interactions towards a dependent resident (Resident 9) and nursing staff call light response. This deficient practice had the potential to effect 4 of 4 residents from Resident Council who communicated facility concerns on behalf of all residents who resided in the facility (Residents 9, 21, 35, 26 and 70).

Inspectors wroteBased on observations and interviews, the facility failed to date insulin pens, and an insulin bottle was expired for 1 of 3 medication carts reviewed and 1 of 2 medication rooms reviewed.

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman of a transfer/discharge to the hospital for 1 of 2 residents reviewed for transfer/discharge notification (Resident 27).

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or resident representative of the bed hold policy for 1 of 2 residents (Resident 27) reviewed for bed hold policy notification.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded to reflect residents' conditions and/or services for 6 of 23 residents reviewed (Residents 2, 35, 36, 39, 46, and 47).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 35) who had a diagnosis of a major mental illness received and/or maintained on file a copy of her Pre-admission Screen and Resident Review (PASARR) Level I & II for 1 of 5 residents reviewed for PASARR.

Inspectors wroteBased on record review and interview, the facility failed to update a resident's care plan when a change had been made to his medications for 1 of 4 residents reviewed for care plan revision (Resident 28).

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for 2 of 2 dependent residents reviewed for ADLs (Resident 14 and 74).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was occasionally incontinent of bowel received appropriate treatment to restore as much normal bowel function as possible for 1 of 1 resident reviewed for bowel incontinence.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident was vaccinated against COVID for 1 of 5 residents reviewed for vaccinations (Resident 55).

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of property (Resident B). The deficient practice was corrected on 12/19/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 residents reviewed for misappropriation (Residents B).

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate an allegation of the misappropriation of property for 1 of 3 residents reviewed for misappropriation of property (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication errors related to administration of transdermal patches (a medication patch applied to the skin) for 1 of 1 resident reviewed for medication errors (Resident Q).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an admission inventory was completed, and failed to ensure discharge medications were counted and documented for 1 of 1 resident reviewed for medication disposition (Resident Q).

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's representative was notified of a left hip wound for 1 of 3 residents reviewed for wounds (Resident C).

Inspectors wroteA. Based on record review and interview, the facility failed to implement care plan interventions to prevent further development of wounds for 1 of 3 residents reviewed for wounds (Resident C).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who fell was not moved before seeking treatment, and was subsequently diagnosed with a hip fracture for 1 of 3 residents reviewed for accidents (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to notify the responsible party of a change in condition of 1 of 1 resident reviewed for change of condition and notification (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to ensure respiratory services order was obtained and entered into the medical record for 1 of 1 resident reviewed for respiratory services (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were provided as ordered by the physician for 1 of 3 residents reviewed for medication administration (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pest control program, throughout the building, was effective for 3 of 3 days of observation which had the potential to affect 100 of 100 residents residing in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services for effective assessment, skin care, and monitoring were provided in a timely manner to a resident that complained of not feeling well for 1 of 3 residents reviewed for quality of care. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for a resident while taking a shower resulting in a fall for 1 of 3 residents reviewed for falls (Resident C).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective supervision to prevent a cognitively impaired resident from exiting the second story locked memory care unit through an open window located approximately 13 feet above the ground by using a gait belt and failed to conduct an elopement assessment when the cognitively impaired resident verbalized the intention to elope from the facility for 1 of 3 residents reviewed for accidents. Resident B sustained a fractured left heel, a fractured left ankle, two fractures of the sacral vertebras, and a thoracic vertebra fracture (Resident B). The immediate jeopardy began on 3/16/24 when a cognitively impaired resident with a diagnosis of Alzheimer's, who was admitted on e day before to the locked memory care unit, was observed with exit seeking behaviors throughout the day on 3/16/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized dementia care and supervision of a newly admitted resident with Alzheimer's dementia for 1 of 3 residents reviewed for dementia care (Resident B) which resulted in the resident exiting the locked memory care unit through a second story window approximately 13 feet above the ground and fracturing her left heel, left ankle, two sacral vertebrae, and a thoracic vertebra. The immediate jeopardy began on 3/15/24 when a cognitively impaired resident with a diagnosis of Alzheimer's dementia was admitted to the nonsmoking locked memory care unit. Resident B was admitted from an assisted living facility, required minimal assistance with ADLs (Activities of Daily Living), and required no supervision when smoking cigarettes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's elopement incident was accurately reported after the resident exited an open window on the second floor sunroom and the resident sustained injuries for 1 of 3 incidents reviewed for accuracy (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left in resident's room without proper supervision and/or a medication self-administration assessment for 3 of 9 residents reviewed for accidents (Residents 76, 79 and 17).

Inspectors wrote2. On [DATE] at 12:02 p.m., Resident 39's record was reviewed. He was admitted on [DATE]. His diagnoses included, but were not limited to, traumatic subdural hemorrhage (bleeding in the brain), cerebral infarction (stroke), and diabetes mellitus (blood sugar disorder). His physician order, dated [DATE], indicated his code status was a full code. His care plans were reviewed. He did not have a care plan for his code status. On [DATE] at 1:35 p.m., the Director of Nursing (DON) provided Resident 39's POST (Physician Orders for Scope of Treatment) form. It indicated he wanted to be a full code. A care plan was added on [DATE], it indicating Resident 39 had a full code status. Interventions included start CPR (cardio-pulmonary resuscitation) and call 911 (emergency services) and review quarterly and as needed for any change in code status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meaningful activities were provided and implemented as scheduled, failed to invite additional residents to activities, and failed to document the participation/engagement in activities of the attending residents. This deficient practice had the potential to affect 39 of 39 residents who resided on the secured memory care unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for accidents by effectively monitoring and maintaining the anti-roll back brake systems on wheelchairs for residents who required them for 3 of 9 residents reviewed for accidents (Residents 63, 85 and 255).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing assistance with eating followed infection control guidelines for 2 of 2 residents observed for residents needing assistance with eating (Resident 41 and 75), and the facility failed to ensure all foods were dated in the kitchen for 1 of 2 observations of the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 72) had the right to privacy during a wound dressing treatment for 1 of 1 resident reviewed for privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Foley (urinary containment device) catheters were not on the floor and a Foley bag had a dignity cover for 2 of 3 residents observed for urinary collection devices (Resident 72 and 79). Findings including: 1 On 2/9/24 at 2:26 p.m., Resident 94's foley bag was observed from the open door of his room, the bag was on the floor and there was not a dignity bag to preserved his dignity. His diagnoses included, but were not limited to, urinary tract infection, chronic kidney disease, and acute (sudden onset) kidney failure. A care plan, dated 11/28/23, indicated Resident 94 was at risk for urinary tract infections (UTI) related to his history of UTIs. The care plan goal was for the resident would have no active UTIs. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition formula was correctly labeled for 1 of 1 resident reviewed for tube feeding management according to policy (Resident 25).