Inspection Reports for
Plainfield Health Care Center

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.

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 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.

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.

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.

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, 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 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.