PLAINFIELD, IN - Federal inspectors documented significant care failures at Plainfield Health Care Center during an April 2025 survey, finding that inadequate staffing levels resulted in residents experiencing prolonged wait times for assistance and improper management of a resident's bowel incontinence that led to painful wound complications.
Chronic Understaffing Leaves Residents Waiting for Basic Care
The inspection revealed systemic staffing shortages that affected all 114 residents at the facility, with particularly severe deficiencies during evening, night, and weekend shifts. Multiple residents reported waiting extended periods for assistance with basic needs, with some experiencing incontinence accidents when help did not arrive in time.
Documentation showed that staffing levels fell far below what residents required for adequate care. On New Year's Day 2025, licensed nurses provided approximately 18 minutes of direct care per resident during day and evening shifts, dropping to just 12 minutes per resident during night shift. Certified nursing assistants (CNAs) provided approximately 36 minutes per resident during day shift and only 18 minutes during night shift.
Weekend staffing patterns revealed similarly concerning shortages. Sunday night shifts were particularly problematic, with licensed nurses providing approximately 10 minutes of direct care per resident. During these periods, CNAs were responsible for approximately 15 residents each, making it physically impossible to respond promptly to all care needs.
The facility's staffing data triggered alerts in the Centers for Medicare and Medicaid Services reporting system for both excessively low weekend staffing and one-star staffing ratings during the first quarter of 2025. Despite these warning indicators, facility administration had not implemented corrective measures or quality improvement plans to address the chronic staffing issues.
Residents Report Being Told to Soil Themselves
The staffing shortage created particularly distressing situations for residents requiring toileting assistance. According to inspection findings, staff members reportedly told residents to "just use the brief" rather than providing bedpan assistance when staffing levels were insufficient. This practice was especially problematic for residents with medical devices or wounds that could become contaminated.
Resident interviews revealed that night shift presented the greatest challenges, with residents reporting they "could never find any staff to help" or experienced extremely long wait times after activating call lights. In some instances, staff would enter rooms to turn off call lights but never return to provide the requested assistance. Four residents participating in a Resident Council meeting confirmed these experiences were widespread and ongoing.
Observations during the inspection confirmed the absence of visible staff presence. Surveyors documented multiple instances when no staff members were observed in hallways or at nursing stations on the rehabilitation unit, leaving residents without immediate access to assistance.
Failed Management of Antibiotic-Related Diarrhea Causes Painful Complications
The inspection uncovered a particularly concerning case involving a resident with a recent above-knee amputation who developed severe diarrhea after starting antibiotic therapy. The resident, who had a wound vacuum device attached to his sacrum (lower back area), experienced significant complications when staff failed to properly manage his bowel incontinence.
The resident had been placed on two different intravenous antibiotics following his March 29, 2025 admission. Medical records showed he began experiencing diarrhea shortly after starting the antibiotic regimen. Despite documenting loose stools and diarrhea on multiple occasions between March 30 and April 3, nursing staff continued administering stool softeners twice daily throughout this period.
This medication error violated basic nursing protocols. When patients develop diarrhea, particularly antibiotic-associated diarrhea, stool softeners should be immediately discontinued as they worsen the condition. The continued administration of laxative medications to a patient already experiencing diarrhea demonstrates a fundamental failure in medication management and clinical assessment.
The consequences proved painful and potentially dangerous. The resident reported that frequent bowel incontinence contaminated his wound vacuum device, requiring daily changes of the apparatus. Each change caused significant pain, requiring the administration of two pain pills beforehand. The contamination of a healing surgical wound with fecal matter significantly increases infection risk and can delay wound healing or cause serious complications.
Medical Protocols Ignored Despite Clear Warning Signs
Standard medical practice requires immediate intervention when patients develop persistent diarrhea during antibiotic therapy. Antibiotics can disrupt normal intestinal bacteria, leading to overgrowth of harmful organisms like Clostridioides difficile (C. diff), a potentially life-threatening infection. Healthcare providers should test for C. diff within 24-48 hours of diarrhea onset in patients receiving antibiotics.
The facility's own care plan, dated March 30, acknowledged that antibiotics could "result in the eradication of beneficial microorganisms and cause secondary infections such as colitis" and that "any antibiotic may cause diarrhea." Despite this documented awareness, staff failed to implement the plan's required interventions, which included monitoring for adverse reactions and observing for side effects.
Proper bowel incontinence management requires individualized assessment and treatment planning. For patients with antibiotic-associated diarrhea, immediate steps should include discontinuing unnecessary laxatives, initiating probiotic therapy, testing for infectious causes, and ensuring meticulous hygiene to prevent skin breakdown and wound contamination. The facility failed to implement any of these standard interventions in a timely manner.
Additional Issues Identified
The inspection revealed several other concerning findings affecting resident care quality. Two residents receiving tube feedings were observed in deteriorated hygiene conditions throughout the week-long survey. Both remained in bed wearing only hospital gowns, with matted, greasy hair and signs of inadequate oral care despite not receiving food by mouth. One resident had long fingernails with dark debris underneath and emitted strong odors of urine and feces when checked.
The facility experienced critical shortages of basic supplies, particularly washcloths needed for incontinence care. As a "wipe-less facility," staff relied entirely on washcloths for cleaning residents after toileting. Laundry service reductions meant supplies often ran out after 3:00 PM, forcing night shift staff to work without adequate materials for basic hygiene care.
Staff interviews revealed that night shift workers frequently left residents unchanged throughout their shifts, creating immediate care backlogs when day shift arrived. This practice meant morning staff began their shifts already behind schedule, perpetuating delays throughout the day.
The facility received fifteen grievances over six months related to call light response times and staff availability, with seven specifically addressing night shift concerns. Despite this pattern of complaints, administration had not implemented performance improvement plans or systematic approaches to address these documented issues.
When questioned about policies regarding bowel incontinence management, facility leadership could not produce any written protocols by the survey's conclusion, indicating an absence of standardized procedures for managing this common condition.
The inspection findings demonstrate how understaffing creates cascading failures throughout a facility's care delivery system, affecting everything from basic hygiene to complex medical management, ultimately compromising resident safety and dignity.
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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