Federal inspectors found Plainfield Health Care Center missed 11 weekly skin checks for one resident between June and September, even as an infected area on the person's right flank deteriorated to the point where 75 percent consisted of dead tissue.
The resident, identified as Resident B, has rhabdomyolysis, a condition where skeletal muscle breaks down and releases harmful substances into the bloodstream. They also have type II diabetes, a history of coccyx fracture, and severe obesity.
A physician ordered weekly skin assessments every Monday evening shift starting December 26, 2024. But staff skipped the checks for June 2, June 23, June 30, July 7, July 28, August 4, August 11, September 1, September 15, September 22, and September 29.
By October 3, a progress note documented the wound's alarming progression. The right flank area showed redness, warmth, and odor with a small amount of light pink, watery drainage. Three-quarters of the wound contained dead tissue, while the remaining quarter had accumulated yellow, tan, and white dead material.
Only then did a nurse practitioner order antibiotics and a specialty mattress.
The facility's own care plan from May 2024 acknowledged that Resident B "would refuse care." Staff were supposed to monitor refusal episodes, determine underlying causes, and document both the behavior and potential reasons. But inspection records show no documentation of refusals for the missed assessments.
A second resident also experienced gaps in required skin monitoring. Resident E, who has chronic obstructive pulmonary disease, toe injuries, diabetes, and dementia, missed weekly skin assessments ordered for Thursdays during the day shift.
Staff failed to complete or document skin checks for August 26, September 2, and September 9. This resident's care plan specifically noted a "potential for pressure ulcer development related to decreased mobility and incontinence" and required weekly head-to-toe skin assessments.
During the October 15 inspection, Director of Nursing told investigators that skin assessments should be completed and documented weekly according to physician orders. If residents refuse, staff should try again later. If refusal continues, that should be documented in the clinical record.
The facility's own wound management policy, revised in June 2020, requires licensed nurses to perform skin assessments upon admission, readmission, weekly, and as needed for each resident. The policy also mandates notifying the attending physician and interdisciplinary team when residents refuse treatment.
Yet neither resident's record contained documentation of refusal for the missed assessments.
The inspection focused on quality of care complaints and reviewed four residents total. Half experienced failures in basic skin monitoring that could prevent serious wounds and infections.
For Resident B, the consequences became clear in that October progress note. What started as missed weekly checks ended with dead tissue, infection, and emergency interventions including antibiotics and specialized bedding.
The facility received a citation for failing to provide appropriate treatment and care according to physician orders and resident preferences. Inspectors classified the violation as causing minimal harm or potential for actual harm.
But for residents with conditions like diabetes, muscle breakdown disorders, and limited mobility, consistent skin monitoring can mean the difference between early intervention and serious complications requiring hospitalization.
The inspection occurred on October 15, 2025, following complaints about care quality. Federal regulations require nursing homes to follow physician orders and document when residents refuse recommended treatments.
Plainfield Health Care Center now faces federal oversight to ensure staff complete ordered assessments and properly document any refusals. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
For Resident B, the missed assessments contributed to a progression from undetected skin problems to an infected wound requiring antibiotics. The October progress note captured the result of months without proper monitoring: dead tissue, drainage, and the smell of infection that should have been prevented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plainfield Health Care Center from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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