Plainfield Health Care Center

Based on record review and interview, the facility failed to complete an Interdisciplinary Team (IDT) post fall assessment and implement post fall interventions for 3 of 3 residents reviewed for accidents. (Resident B, E, and F) Findings include:1.

The clinical record for Resident B was reviewed on 11/6/25 at 10:21 a.m.

Diagnoses included history of stroke affecting left side, epilepsy, and dementia with behavioral disturbance.A health care plan, dated 6/22/25, indicated the resident was a high risk for falls related to confusion, incontinence and poor comprehension/communication.Resident B's progress notes lacked documentation of an IDT review of falls on 8/13/25, 8/17/25, 8/21/25, 8/22/25, and 8/23/25.

The resident's care plan lacked an added intervention for the fall on 8/23/25.2.

The clinical record for Resident E was reviewed on 11/6/25 at 12:05 p.m.

Diagnoses included senile degeneration of the brain, convulsions, dementia, and difficulty walking.A health care plan, revised on 9/5/25, indicated the resident was a high risk for falls related to gait/balance problems, incontinence, safety awareness, and medication side effects.Resident E's progress notes lacked documentation of an IDT review of falls on 8/15/25, 9/2/25, 9/4/25, 9/5/25, 9/17/25, and two falls on 9/18/25.

The resident's care plan lacked added interventions for the falls on 8/15/25 and 9/2/25.3.

The clinical record for Resident F was reviewed on 11/6/25 at 12:57 p.m.

Diagnoses included intercranial injury with loss of consciousness, difficulty walking, repeated falls, dementia, and Parkinson's disease.A health care plan, revised 10/13/25, indicated the resident was a high risk for falls related to an unsteady gait, walking too fast, Parkinson's disease, and a history of traumatic brain injury.Resident F's progress notes lacked documentation of an IDT review of a fall on 8/12/25, 8/13/25, 8/30/25, 10/6/25, 10/11/25, 10/15/25, and 10/18/25.

The resident's care plan lacked an added intervention for falls on 10/6/25.

During an interview on 11/6/25 at 1:39 p.m., the Director of Nursing (DON) indicated an Interdisciplinary Team (IDT) review had been completed during the following morning meeting for the resident's falls, however, he had failed to document the root cause and review of the IDT and had also failed to add interventions for some of the falls.

This should be completed and documented with each resident fall.A current facility policy, undated, titled, Response to Falls, provided by the Administrator on 11/7/25 at 9:20 a.m., included the following: Purpose To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention.

Policy.V.

The Interdisciplinary Team (IDT) will review the investigative reports on a regular basis, as they many occur, and make systemic changes to reasonably limit future occurrences, consider change in POC [plan of care] interventions, system changes, etc.II.

Post-Fall Assessment and Monitoring.C.

Following each resident fall, the Interdisciplinary Team (IDT)-Falls Committee will review the Post-Fall Assessment & Assessment within 72 hours, or as soon as practicable. i.

Based on the Post-Fall Assessment & Investigation, the IDT Committee will review fall prevention interventions and modify the plan of care as indicated.This citation relates to Intake 2659706.3.1-45(a)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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