Inspection Reports for
Plainfield Health Care Center

The complaint investigation involved allegations of failure to notify physician or family of injury, failure to report and investigate suspected abuse or neglect, failure to follow physician medication orders, and failure to provide adequate supervision for an aggressive dementia resident. The complaint was substantiated with findings of multiple deficiencies including immediate jeopardy related to resident safety.

The facility failed to notify appropriate personnel about a resident's injury, failed to investigate the injury properly, failed to follow physician ordered medication parameters for two residents, and failed to provide adequate supervision and care for an aggressive dementia resident, resulting in injury to another resident. Immediate jeopardy related to resident safety was identified but removed after the aggressive resident was transferred to an acute care hospital.

This citation relates to Intake 2659706. The complaint investigation found the facility did not document IDT reviews or add interventions for falls as required.

The facility failed to complete Interdisciplinary Team (IDT) post-fall assessments and did not implement post-fall interventions for 3 residents reviewed. Documentation of IDT reviews and added interventions for multiple falls were missing in the clinical records.

This citation relates to Intake 2636572. The complaint was substantiated based on record review and interviews confirming missed skin assessments and lack of documentation of refusals.

The facility failed to complete or document weekly skin assessments for 2 of 4 residents reviewed, resulting in potential risk for pressure ulcers and wound complications. The Director of Nursing confirmed that skin assessments should be completed weekly as ordered or refusals documented.

The visit was complaint-related, addressing failures in physician notification for abnormal blood sugar levels and incomplete skin assessments. The citation is related to Intake 2563360 and Intake 2580813.

The facility failed to notify the physician of blood sugar values outside ordered parameters for one resident and failed to complete weekly skin assessments for another resident as ordered. Documentation of physician notifications and skin assessments was incomplete or missing.

The facility was found not in compliance with several Life Safety Code requirements including egress door accessibility, emergency lighting testing, smoke alarm maintenance, hazardous area door self-closing devices, kitchen hood extinguishing system appliance placement, fire alarm system date/time accuracy, sprinkler system inspection documentation, electrical panel security, laundry room electrical safety, and patient care related electrical equipment maintenance.

The facility failed to provide adequate nursing staff to meet resident needs, resulting in delayed assistance and unmet care needs. Deficiencies were found in resident grievance follow-up, transfer/discharge notifications, accurate resident assessments, care plan updates, ADL care, bowel incontinence management, medication labeling, and COVID-19 vaccination documentation.

Complaints IN00455987 and IN00456156 were investigated with no deficiencies related to the allegations cited.

The facility was found deficient in multiple areas including inadequate nursing staff leading to delayed ADL care, failure to notify ombudsman of resident transfer, inaccurate MDS assessments, failure to update care plans after medication changes, inadequate ADL care for dependent residents, improper bowel incontinence management, expired and undated insulin medications, and failure to ensure COVID-19 vaccination for a resident.

Multiple complaints (IN00446484, IN00449428, IN00451783, IN00451862, IN00452158, IN00452303, IN00452675, IN00452714, IN00453379, IN00453464, IN00453723) were investigated. Deficiencies related to misappropriation of property and medication errors were substantiated in complaints IN00449428 and IN00453464.

The facility failed to protect a resident from misappropriation of property by a former staff member, failed to report and investigate the alleged crime timely, and failed to ensure medication safety and proper medication disposition. Additionally, a QMA worked with an expired license.

The complaint involved allegations of misappropriation of Resident B's funds by a former Social Service Assistant and medication errors involving Resident Q. The facility was found to have failed in protecting Resident B's property rights and in investigating and reporting the incident. Additionally, Resident Q experienced medication errors related to transdermal patch administration and improper medication disposition documentation.

The facility failed to protect Resident B from misappropriation of property by a former staff member and failed to thoroughly investigate the allegations. The facility also failed to ensure Resident Q was free from significant medication errors related to transdermal patch administration and failed to maintain proper medication disposition documentation upon discharge.

This citation relates to Complaints IN00445177, IN00445565, IN00445570, and IN00445476. The complaints involved failure to notify a resident's representative of a wound, failure to implement wound care plans, and improper management of a resident's fall and injury.

The facility failed to notify a resident's representative of a left hip wound and failed to develop and implement care plans to prevent further wound development. Additionally, the facility failed to ensure a resident who fell was not moved before seeking treatment, resulting in delayed diagnosis and treatment of a hip fracture.

The investigation involved complaints IN00445177, IN00445565, IN00445570, and IN00445476. The complaints included failure to notify family of wounds, failure to implement wound care plans, and improper handling of a resident fall resulting in injury. The complaints were substantiated with deficiencies cited accordingly.

The facility was found deficient in notifying a resident's representative of a left hip wound, failing to implement care plan interventions to prevent wound development, and not properly managing a resident fall which resulted in a hip fracture. Deficiencies were cited related to notification of changes, care planning, and quality of care.

This citation relates to Complaints IN00441980, IN00441976, and IN00442404. The complaints involved failure to notify family of condition changes, failure to document respiratory orders, and failure to administer medications as ordered.

The facility failed to notify the responsible party of a resident's change in condition, failed to ensure respiratory services orders were properly documented, and failed to provide medications as ordered for one resident. These deficiencies contributed to inadequate care and the resident's subsequent death.

The investigation was triggered by complaints IN00441980, IN00441976, and IN00442404. The complaints alleged failures in notification of changes in condition, respiratory care orders, and medication administration for Resident B. The complaints were substantiated with deficiencies cited at F580, F695, and F755.

The facility failed to notify the responsible party of a resident's change in condition, failed to ensure respiratory services orders were properly obtained and documented, and failed to provide medications as ordered by the physician for one resident. These deficiencies were related to complaints and involved Resident B's care, including notification failures, respiratory care, and medication administration.

The investigation was triggered by complaints IN00438940, IN00432231, IN00437783, IN00437780, and IN00437462 concerning inadequate care leading to skin breakdown and hospitalization, fall risk and supervision failures resulting in a resident fall and death, and pest infestations throughout the facility.

The facility failed to provide timely and effective care for a resident with skin integrity issues leading to hospitalization, failed to supervise a resident during shower resulting in a fall and death, and had an ineffective pest control program with persistent flying insect infestations throughout the building.

This investigation was triggered by multiple complaints (IN00438940, IN00438234, IN00438150, IN00437780, IN00437783, IN00437462, IN00436746, IN00435654, IN00432231) alleging quality of care issues, inadequate supervision, and pest control problems. Some complaints were substantiated with deficiencies cited, others were not.

The facility was found deficient in providing timely and effective care to a resident with an ileostomy leading to severe skin breakdown and hospitalization, failed to provide adequate supervision to a resident resulting in a fall during showering, and had an ineffective pest control program evidenced by persistent flying insects throughout the building.

Complaint IN00430638 had no deficiencies related to the allegations. Complaint IN00430651 resulted in federal/state deficiencies cited at F609, F689, and F744 related to the resident elopement incident and quality of care.

The facility failed to ensure accurate reporting of a resident elopement incident and failed to provide adequate supervision and individualized dementia care for a cognitively impaired resident who exited a second story window, resulting in multiple fractures. The resident's care plan and assessments were incomplete, and staff failed to notify appropriate personnel of exit-seeking behaviors. Immediate jeopardy was identified and later removed after corrective actions were implemented.

This citation relates to Complaint IN00430651. The complaint involved a resident who eloped from the secured memory care unit through a second story window, resulting in serious injuries. The resident's family expressed concerns about the incident and the facility's handling of the situation.

The facility failed to provide adequate supervision and effective dementia care to prevent a cognitively impaired resident from exiting the secured memory care unit through an open second story window. The resident sustained multiple fractures after the fall. The facility lacked proper elopement risk assessments, care plans, and timely reporting of the incident. Immediate jeopardy was identified but later removed after corrective actions.

The facility was found not in compliance with Life Safety Code requirements, including expired inspection certificates for 10 fuel fired water heaters, a set of smoke barrier doors that did not close properly, and unsecured electrical outlets and panels. Corrective actions and plans of correction were documented with compliance dates in March 2024.

The facility was found deficient in multiple areas including medication self-administration assessments, resident privacy during care, comprehensive care planning, meaningful activity provision, wheelchair safety, catheter care, feeding tube management, and infection control during feeding assistance and food storage.

The facility was found deficient in multiple areas including medication self-administration assessments, resident privacy during care, PASARR coordination, care plan revisions, activity programming, accident prevention related to wheelchair brakes, Foley catheter care, enteral feeding labeling, and food safety practices.

The facility was found not in compliance with Life Safety Code requirements due to obstructions in one means of egress and the use of prohibited portable space heaters. Immediate interventions were taken to remove the obstructions and heaters, and plans for ongoing monitoring were established.

The facility was found not in compliance with NFPA 101 Life Safety Code requirements due to incomplete sprinkler system installation and lack of a reliable fuel source letter for the emergency generator. The sprinkler heads on the Memory Care unit were spaced less than 6 feet apart, and the facility lacked documentation from the natural gas provider confirming reliability of the fuel source.

The complaint investigation included issues with Medicare Non-Coverage notices, Minimum Data Set accuracy, nutritional care and hydration, respiratory care equipment management, dialysis care documentation, meal/snack provision, and infection preventionist designation. Substantiation is implied by the detailed findings and citations.

The facility failed to provide timely Medicare Non-Coverage notices, ensure accurate Minimum Data Set assessments, provide adequate nutritional support and hydration resulting in significant weight loss and abnormal labs, maintain safe respiratory care with proper oxygen and bipap equipment management, perform and document dialysis pre/post assessments, provide evening snacks despite a 15-hour gap between dinner and breakfast, and designate a qualified infection preventionist fulfilling required duties.

The facility was cited for multiple deficiencies including failure to timely provide Medicare Non-Coverage notices, inaccurate Minimum Data Set (MDS) assessments, inadequate nutrition and hydration support resulting in significant weight loss and abnormal labs, lack of physician orders for respiratory care equipment maintenance, failure to perform pre/post dialysis assessments, failure to provide evening snacks when meal intervals exceeded 14 hours, lack of a qualified infection preventionist, and employment of a staff member with an expired license.