Plainfield Nursing Home Failed to Provide Basic Hygiene Care and Maintain Proper Documentation
PLAINFIELD, IN - A state inspection of Plainfield Health Care Center documented multiple instances where residents requiring total assistance with daily care received inadequate hygiene services, while administrative failures left critical mental health screening documentation incomplete or missing entirely.
Systemic Hygiene Care Failures for Dependent Residents
During an April 2025 inspection, state surveyors documented concerning conditions affecting two residents who were completely dependent on staff for all aspects of personal care. The findings revealed a pattern of incomplete or delayed hygiene services that left vulnerable residents in compromised conditions for extended periods.
Resident 14, who received nutrition through a gastrostomy tube and had paralysis affecting her left side following a stroke, was observed over multiple days in conditions that indicated inadequate attention to basic care needs. On April 2nd, surveyors noted the resident had long fingernails with dark debris underneath, greasy and matted hair, and despite receiving no nutrition by mouth, exhibited dry lips and a foul breath odor indicating poor oral hygiene.
These conditions persisted throughout the inspection week. By April 7th, when staff were asked to check on the resident, a certified nursing assistant discovered she was lying in clothing and linens soaked with urine extending to the middle of her back, along with fecal incontinence. The staff member indicated it appeared the resident had not been changed throughout the entire night shift and had not yet received morning care.
The medical significance of these lapses extends beyond comfort concerns. Prolonged contact with urine and feces can lead to skin breakdown, particularly dangerous for individuals with limited mobility who cannot reposition themselves. The resident's stroke-related paralysis made her especially vulnerable to pressure injuries. Additionally, inadequate oral hygiene in medically complex patients can contribute to aspiration pneumonia and other respiratory complications, even in those receiving tube feeding.
Resident 74, a younger resident with cerebral palsy who had been admitted from a group home for post-surgical rehabilitation, faced similar care deficits. Throughout the inspection week, she was repeatedly observed with greasy, matted hair flattened from wearing a protective helmet. Her hair showed multiple matted sections that appeared to have gone unaddressed for an extended period.
During confidential staff interviews, surveyors learned that some caregivers avoided providing complete hygiene care to this resident because she could become combative, attempting to kick or bite during care activities. Staff indicated the resident refused bed baths approximately half the time, and they were uncertain when her hair had last been properly brushed or whether anyone had attempted to address the matting.
This situation highlights a critical gap in care planning for residents with behavioral responses to care. When individuals cannot verbally communicate their needs or preferences due to cognitive or developmental conditions, facilities must develop specialized approaches that respect the resident's dignity while ensuring necessary care is provided. The absence of documented strategies for working with this resident's care-related behaviors represented a failure in the individualized care planning process.
Documentation Failures Affecting Mental Health Services
The inspection identified systematic failures in maintaining and coding Pre-Admission Screening and Resident Review (PASARR) documentation for residents with serious mental illness. This federal requirement ensures individuals with mental health conditions receive appropriate specialized services and are placed in suitable care settings.
PASARR screening serves as a safeguard preventing inappropriate institutional placement of individuals whose needs might be better met in alternative settings. The Level II evaluation determines whether a nursing home can appropriately meet a person's needs and identifies any specialized mental health services required. Without proper documentation of these evaluations, facilities cannot demonstrate they are providing the appropriate level of mental health support.
The facility failed to maintain Level I or Level II PASARR documentation for Resident 35, who had been diagnosed with bipolar disorder. While the evaluations had been completed at her previous facility and remained accessible in the online system, no one transferred this critical documentation to her current facility record during the transition between social service directors.
This administrative gap had cascading effects on the resident's care. The absence of PASARR documentation meant her care plan was never revised to reflect her Level II status or address any specialized mental health service needs identified in the evaluation. Her admission assessment in September 2024 failed to code her PASARR Level II status, creating an incomplete picture of her care requirements.
Similar documentation failures affected three additional residents with serious mental illness diagnoses including major depressive disorder, post-traumatic stress disorder, and schizoaffective disorder. In each case, the most recent comprehensive assessments failed to properly code PASARR Level II status, despite these evaluations being fundamental to appropriate mental health care planning.
The implications of these documentation failures extend beyond paperwork compliance. PASARR evaluations identify specific mental health service needs and determine whether a nursing home setting can appropriately meet those needs. When facilities fail to incorporate this information into care planning and assessment documentation, they cannot demonstrate they are addressing the specialized mental health requirements that may be critical to a resident's well-being.
Additional Issues Identified
The inspection revealed other care planning and documentation concerns. One resident's care plan continued to indicate he required antidepressant medication for depression, despite his medication regimen no longer including any antidepressant. This discrepancy occurred after the resident returned from hospitalization with changed medications, but the care plan was never updated to reflect the modifications.
Another resident receiving hospice services had assessment documentation incorrectly indicating she was not receiving hospice care, despite hospice orders being active in her medical record since early March 2025. The error occurred during completion of a significant change assessment and required immediate correction when identified.
Both situations reflected gaps in the interdisciplinary review process that should catch such discrepancies. Accurate care plan documentation serves as the communication tool coordinating all aspects of a resident's care across nursing, medical, therapy, dietary, and other services. When care plans contain outdated or incorrect information, the risk of care delivery errors increases substantially.
Medical Standards and Expected Practices
Federal nursing home regulations require facilities to provide care and services to help each resident attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. For residents unable to perform activities of daily living independently, this means facilities must provide necessary assistance with bathing, dressing, grooming, oral hygiene, and toileting.
The standard of care requires that residents dependent on staff for hygiene needs receive regular, consistent attention to these fundamental aspects of personal care. Industry best practices call for comprehensive assessment of each resident's hygiene needs, preferences, and any barriers to care delivery, with individualized approaches developed for residents who exhibit care-resistant behaviors.
For residents with cognitive impairments or communication deficits who may respond to care with defensive behaviors, evidence-based approaches focus on identifying triggers, modifying the care environment, adjusting caregiver techniques, and sometimes involving behavioral health specialists. Simply avoiding or delaying necessary care due to behavioral responses fails to meet professional standards.
Regarding mental health documentation, PASARR represents a fundamental protection for individuals with serious mental illness entering nursing home care. The screening process ensures appropriate placement and identifies specialized service needs. Facilities must maintain this documentation and incorporate findings into care planning and assessment processes. The transition of residents between facilities or changes in facility staffing do not eliminate these documentation requirements.
The facility acknowledged the documentation errors occurred during a transition period when the social service director position changed, with several items incorrectly coded during that transition. While staffing changes present operational challenges, regulatory requirements for comprehensive assessment and care planning remain constant, necessitating systems that ensure continuity during transitions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plainfield Health Care Center from 2025-04-07 including all violations, facility responses, and corrective action plans.
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