Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Health & Rehab Center Of Plainfield, Llc during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, right-sided hemiplegia, and a fall history had increasing transfer weakness and fatigue that were observed by NA and RN staff but not reported or reflected in the care plan. During a toileting transfer, the resident could not bear weight, the transfer was continued anyway, and the resident fell, striking the face. After the fall, the NA left the resident on the floor unattended, and later transfers required four staff while the resident grimaced, clenched the jaw, and complained of severe pain. The resident was later found to have an acute intertrochanteric femur fracture requiring ORIF.
A resident with dementia, chronic pain syndrome, aphasia, and generalized weakness did not receive pain management in accordance with the care plan and pain policy. PRN analgesics were not reassessed within the required hour on multiple occasions, and after a fall the resident showed severe pain with grimacing, clenched teeth, and pain during transfers that staff did not treat as a change in condition requiring provider notification. Pain medication was also delayed after the fall, and the resident was later found to have an acute intertrochanteric fracture of the right proximal femur requiring ORIF.
A resident with severe cognitive impairment and mobility limitations was injured during a mechanical lift transfer when the upper sling strap detached, causing the resident to fall and sustain a head hematoma and vertebral fracture. Two NAs performed the transfer but did not verify that all sling straps were securely attached, contrary to facility policy.
A resident with severe cognitive impairment was involved in an incident where a NA allegedly hit them on the chest after the resident became combative and scratched the NA. The incident was reported by another NA present, and the resident confirmed the event. The facility substantiated the abuse, leading to the termination of the NA's employment.
A resident with severe cognitive impairment alleged inappropriate touching by a male NA. The allegation was reported to a NA, who delayed reporting it to the facility, contrary to policy. The incident was eventually reported by another NA, leading to a deficiency finding.
The facility failed to date opened food items and improperly stored a staff member's lunch bag in the walk-in refrigerator with resident food, contrary to facility policy. Opened and undated items were found in the dry storage area and main freezer, and a staff member admitted to storing personal food in the refrigerator, despite being aware of the policy against it.
The facility failed to properly document and honor the advance directives of two residents. One resident's signed DNR was not reflected in the physician's orders, which incorrectly indicated a full code status. Another resident's advance directive consent form was missing from the medical record, despite the care plan and physician's orders indicating a DNR status. These discrepancies highlight a failure to adhere to facility policy regarding the management of advance directives.
A resident with a history of falls and moderate fall risk did not receive prescribed fall prevention interventions, such as floor mats and skid strips, due to a lack of communication and updates in the facility's care documentation. Staff were unaware of the resident's fall risk status, as the necessary interventions were not included in the electronic Kardex, leading to a failure in implementing the care plan.
The facility failed to follow physician orders for a resident with diabetes and hypertension, resulting in unreported abnormal glucose levels and missed blood pressure monitoring. Another resident received incorrect medications due to an LPN's failure to properly identify them, leading to drowsiness. Additionally, a resident with COPD was given oxygen without a physician's order, contrary to facility policy.
A facility failed to supervise a resident with dysphagia during meals, as required by physician orders, leading to unsupervised eating and potential aspiration risk. Additionally, the facility did not maintain water temperatures within the safe range of 105 to 120 degrees Fahrenheit in 17 rooms, with temperatures recorded as high as 130 degrees, contrary to the facility's policy.
A resident with chronic kidney disease and legal blindness experienced an allergic reaction to peanut butter, which was documented by the facility but not communicated to the hemolytic treatment center. The resident was sent to the center with peanut butter crackers, which they refused due to the allergy. The W10 transfer form was not updated, and the allergy was not noted in the treatment center's records.
A resident's room in an LTC facility had damaged furniture, including a footboard and dressers, which had been in disrepair for at least three months. The resident, who is legally blind and uses an electric wheelchair, reported the damage, but it was not addressed due to communication lapses among staff. The facility's policy required reporting and repairing damaged furniture, but this was not effectively followed.
The facility failed to investigate grievances filed by six residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Residents reported issues such as dismissive behavior from the DNS, long wait times for call bell responses, feeling rushed by a NA, and concerns about a NA's approach. The grievances lacked proper documentation and investigation, including interviews or statements from involved parties, as required by the facility's grievance policy.
A resident with severe dementia and a history of exit-seeking behavior was able to leave the facility unsupervised when a visitor held the door open and the wander guard alarm failed to activate. Despite being on frequent safety checks and having a wander guard device, the system did not function as intended, and staff did not observe the resident leaving, resulting in the resident being found outside by a staff member.
Inadequate Transfer Supervision and Response to Pain
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during transfers for a resident with dementia, chronic pain syndrome, aphasia, generalized muscle weakness, right-sided hemiplegia, right-hand contracture, and atrial fibrillation on apixaban. The resident’s quarterly MDS identified substantial assistance was needed for transfers, frequent pain was reported, and there was a history of falls. The care plan identified the resident as a moderate fall risk related to gait and balance problems, right-sided hemiparesis, and prior falls, and noted increased difficulty with transfers due to lower extremity weakness. A physician’s order directed a one-person assist stand-pivot transfer with a grab bar for toileting. For at least two weeks before the fall, NA #1 observed the resident was increasingly difficult to transfer during evening and night hours and required a two-person assist because of increased weakness, but this change was not reported to a licensed nurse. RN #3 also observed intermittent fatigue in the days before the fall. Despite these changes, no update was made to the plan of care or transfer approach. During the transfer on the day of the fall, NA #1 stated the resident was unable to bear weight when attempting to stand, but the transfer was continued instead of stopping and obtaining assistance. The resident’s right knee gave out, the resident fell forward, and struck the right side of the face on the wall next to the toilet before landing on the floor. After the fall, NA #1 reported the resident was grimacing and moaning in pain, but removed the gait belt and left the resident unattended on the bathroom floor to get help at the nurse’s station rather than using the bathroom call bell or calling for immediate assistance. When staff later transferred the resident from the floor, the resident required four staff members and showed facial grimacing, jaw clenching, and complaints of severe pain during the transfers to the wheelchair and then to the bed. The resident continued to complain of right hip and leg pain, and the right leg was later observed to be shortened by approximately 1.5 to 2 inches. Hospital records confirmed an acute impacted intertrochanteric fracture of the right proximal femur, and open reduction and internal fixation was performed.
Failure to Reassess and Respond to Pain After PRN Medication and a Fall
Penalty
Summary
Licensed nurses failed to manage a resident’s pain in accordance with the facility’s pain management policy and the resident’s care plan. The resident had dementia without behavioral disturbances, chronic pain syndrome, aphasia, and generalized muscle weakness, and the care plan identified chronic pain, pain and spasms to the right calf, and a communication deficit requiring alternative communication tools and adequate time to respond. Physician orders included acetaminophen and oxycodone-acetaminophen as needed for pain, and the facility policy required pain to be assessed before administration and again about one hour afterward, with physician notification if pain relief was ineffective. On multiple occasions, pain reassessments were not completed within one hour after as-needed pain medication was given. Oxycodone-acetaminophen administered at 3:16 AM on 4/20/26 was not followed by a documented pain reassessment until 5:33 AM. Oxycodone-acetaminophen given at 8:16 PM on 4/21/26 was not reassessed until 11:10 PM, after the resident had already fallen, and that assessment documented the medication was ineffective with pain rated 8 out of 10. Methocarbamol given at 10:23 PM on 4/21/26 also was not documented as reassessed within one hour. After the resident fell at 10:15 PM on 4/21/26 and complained of pain to the right knee and leg, staff observed facial grimacing, clenched teeth, and severe pain during transfers that required four staff members. Despite these signs, the nurses did not identify the condition as requiring provider notification or stop the transfer. Pain medication was not administered until 11:12 PM, about 57 minutes after the fall and after pain had been identified. The resident continued to complain of right hip and leg pain and was later transferred to the ED, where an acute impacted intertrochanteric fracture of the right proximal femur was confirmed and ORIF was performed on 4/27/26.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with dementia and osteoporosis, who was severely cognitively impaired and dependent for transfers, was not safely transferred using a mechanical lift as ordered by the physician and outlined in the care plan. During a transfer from bed to wheelchair by two nurse aides, the upper left strap of the mechanical lift sling detached from the hook, causing the resident to partially slip from the sling and strike their head and shoulder on the ground. The resident sustained a hematoma to the back right side of the head and was subsequently transferred to the hospital, where an acute L2 vertebral fracture was identified. Interviews with the nurse aides involved revealed that one aide attached the lower straps while the other attached the upper straps, but neither verified that all straps were fully secured before lifting the resident. Both aides acknowledged that they did not check the security of the straps prior to moving the resident off the bed. Facility policy required special care and attention when using a mechanical lift, including ensuring all straps are securely attached before lifting. The failure to confirm the proper attachment of the sling straps directly led to the resident's fall and injury.
Resident Abuse Incident Involving Nursing Assistant
Penalty
Summary
The facility failed to protect a resident from mistreatment, resulting in a substantiated case of abuse. The resident, who had severe cognitive impairment and was dependent on assistance for activities of daily living, was involved in an incident where two nursing assistants (NAs) were providing care. During this care, the resident became combative and scratched one of the NAs. In response, the NA allegedly grabbed the resident's arm and hit the resident on the chest with an open hand. This action was reported by the other NA present, and the resident confirmed the incident when interviewed by both facility staff and local police. The facility's documentation and interviews revealed that the NA involved denied hitting the resident, despite the allegations and the resident's statement. The facility conducted a skin assessment and found self-inflicted scratches on the resident's chest but no additional injuries. The incident was substantiated as abuse, and the NA's employment was terminated. The facility's policies on conduct and abuse prohibition were reviewed, highlighting the expectation for staff to maintain professional conduct and prohibit any form of abuse.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving a resident with severe cognitive impairment, dementia, anxiety, and depression. The resident, who required assistance with activities of daily living and was frequently incontinent, alleged that a male nursing assistant touched them inappropriately. The allegation was initially reported to a nursing assistant (NA #3) on 11/8/2024, but NA #3 did not report it to the facility until 11/11/2024. This delay in reporting was contrary to the facility's policies, which require immediate reporting of any suspected abuse. The incident was eventually reported by another nursing assistant (NA #4) after being informed by NA #3. The Director of Nursing Services confirmed that the allegation should have been reported immediately when it was first made. The facility's documentation showed that NA #3 had completed training on abuse reporting but had not yet taken the state exams. The failure to report the allegation promptly led to a deficiency being identified during the survey.
Improper Food Storage and Labeling in Dietary Department
Penalty
Summary
The facility failed to ensure that food items were properly dated when opened and that staff personal food items were not stored in the facility's walk-in refrigerator, as per the facility's policy. During a tour of the Dietary Department, several opened and undated food items were identified in both the dry storage area and the main freezer. These included a box of oatmeal cookies, a box of Oreo cookies, a 5-gallon bucket of chicken base, a bag of fried steak, a bag of Salisbury steak, uncooked pie shells, cooked apple pies, and boxes of frozen cookies. Additionally, in the walk-in refrigerator, an opened and undated 5-gallon bucket of pickles was found alongside a staff member's lunch bag, which was improperly stored with resident food items. Interviews with the Food Service Director (FSD) and Dietary Aide #1 revealed that the FSD and the chef were responsible for dating opened items, but the FSD could not explain why the items were undated. Dietary Aide #1 admitted to storing her lunch bag in the walk-in refrigerator, acknowledging that she was aware of the facility's policy prohibiting personal food storage in that area. The facility's food storage policy mandates that dry storage foods be dated as appropriate and cold foods be labeled and dated, which was not adhered to in this instance.
Failure to Document and Honor Advance Directives
Penalty
Summary
The facility failed to properly manage and document advance directives for two residents, leading to discrepancies between the residents' wishes and the medical orders in their records. For Resident #40, who was diagnosed with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, the facility did not transcribe the advance directives according to the resident's signed wishes. Although the resident had a signed Do Not Resuscitate (DNR) form, the physician's orders incorrectly indicated a full code status, meaning cardiopulmonary resuscitation (CPR) should be performed. The Registered Nurse (RN) and Director of Nursing (DNS) were unable to locate the signed advance directive in the electronic health record (EHR) or paper chart, and the DNS acknowledged that the nurse had mistakenly transcribed the resident's code status from hospital discharge paperwork. For Resident #46, who was admitted with vascular dementia and other mental health conditions, the facility failed to ensure that a signed advance directive consent form was available in the medical record. Although the resident's care plan and physician's orders indicated a DNR status, the signed consent form could not be located in the chart. The DNS was uncertain if there had been a signed advance directive prior to the surveyor's inquiry. The facility's policy required that advance directives be completed and placed in the medical record upon admission, but this was not adhered to, resulting in a lack of documentation to support the resident's end-of-life care preferences.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of falls, as outlined in the Resident Care Plan (RCP). The resident, who had diagnoses including dementia, lack of coordination, and abnormality of gait and mobility, was identified as having a moderate risk for falls. Despite the RCP specifying interventions such as the placement of a floor mat and skid strips, these measures were not observed in the resident's room during a survey. The absence of these interventions was confirmed through interviews with staff, who were unaware of the need for these fall prevention measures. The deficiency was further highlighted by the fact that the electronic Kardex, which staff relied on for resident care instructions, did not include the necessary fall prevention interventions for the resident. This oversight led to a misunderstanding among staff regarding the resident's fall risk status. Interviews with nursing staff revealed that the responsibility for updating the Kardex with RCP information lay with the Nurse Supervisor, but this had not been done, resulting in the failure to implement the prescribed fall prevention strategies.
Deficiencies in Physician Order Compliance and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for Resident #30, who had diagnoses including type 2 diabetes, hypertension, and vascular dementia. The resident's care plan required monitoring of vital signs and blood glucose levels, with specific instructions to notify the physician if glucose levels were outside the specified range. However, on multiple occasions, Resident #30's blood glucose levels were recorded as being outside the acceptable range, yet there was no documentation or evidence that the physician was notified. Additionally, an order for daily blood pressure monitoring was not transcribed into the electronic medical record, resulting in missed opportunities to monitor the resident's condition. In another incident, the facility failed to administer medications correctly to Resident #34, who had severe cognitive impairment and required assistance with daily activities. On one occasion, the resident was mistakenly given another resident's medications, leading to drowsiness and the need for close monitoring. The error was attributed to the LPN's failure to properly identify the resident before administering the medications, despite having multiple methods available for resident identification. Furthermore, the facility did not obtain a physician's order for oxygen administration for Resident #40, who had chronic obstructive pulmonary disease (COPD). The resident was observed receiving oxygen therapy without a corresponding physician's order or documentation in the care plan. This oversight was identified during a review of the resident's records, which lacked any mention of oxygen use, despite the facility's policy requiring physician orders for such treatments.
Failure to Supervise Resident During Meals and Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to appropriately supervise a resident during mealtime as per the physician's order. The resident, who had diagnoses including dementia, dysphagia, and pneumonia with respiratory failure, was required to be supervised and out of bed with an upright posture during meals. Despite these orders, observations revealed that the resident was left unsupervised while eating in their room on multiple occasions. Interviews with the speech therapist and advanced practice registered nurse confirmed that the resident required supervision to minimize the risk of aspiration or choking, yet the nursing assistant failed to provide this supervision, citing a lack of awareness of the care card instructions. Additionally, the facility failed to maintain water temperatures within the acceptable range of 105 to 120 degrees Fahrenheit in 17 out of 50 rooms. Observations showed water temperatures exceeding this range, with some reaching as high as 130 degrees. The Maintenance Director was under the impression that the acceptable range extended to 125 degrees, and the mixing valve was set at 145 degrees. The facility's temperature logs indicated that for a significant portion of the year, water temperatures were recorded above the acceptable limit, with the highest being 130 degrees. The Administrator acknowledged that the water system could be adjusted to lower the temperatures quickly, but this had not been done prior to the surveyor's inquiry. The facility's Water Temperature Policy and Procedure clearly stated that water temperatures should not exceed 120 degrees to ensure safety, yet this standard was not consistently met, posing a potential hazard to residents.
Failure to Communicate Allergy to Treatment Center
Penalty
Summary
The facility failed to communicate a new allergy to the hemolytic treatment center for a resident with chronic kidney disease, end-stage renal disease, diabetes, and legal blindness. The resident, who was cognitively intact and required assistance for daily activities, experienced an allergic reaction to peanut butter, which was documented in the facility's records. However, the allergy was not updated on the W10 transfer form that accompanied the resident to the treatment center, nor was it communicated to the center's staff. As a result, the resident was sent to the treatment center with peanut butter crackers, which the resident refused due to the known allergy. Interviews with the resident, facility staff, and the treatment center employee revealed that the allergy was not documented in the electronic medical record at the treatment center, and the W10 form had not been updated since March 2024. The Director of Nursing confirmed that the allergy was first noted in August 2024, but there was no documentation that the treatment center had been informed. The facility's policy required a licensed nurse to review and update communication forms for changes, which was not adhered to in this case.
Failure to Maintain Homelike Environment Due to Damaged Furniture
Penalty
Summary
The facility failed to maintain a homelike environment for a resident by not ensuring that the furniture in the resident's room was in good repair. Observations revealed that the footboard and two dressers in the resident's room were damaged, with the footboard having a significant portion missing and the dressers missing pieces of veneer. The resident, who is legally blind and uses an electric wheelchair, reported that the furniture had been damaged for at least three months and had not been repaired despite requests. Interviews with facility staff, including the Maintenance Director and Maintenance Assistant, indicated a lack of communication and follow-through regarding the repair of the damaged furniture. The Maintenance Director was aware of the dresser damage but not the footboard, and the Maintenance Assistant did not check for damaged furniture during monthly room checks. The facility's policy required staff to report damaged furniture to the Maintenance Department, but this was not effectively implemented, leading to the prolonged disrepair of the resident's furniture.
Failure to Investigate Resident Grievances
Penalty
Summary
The facility failed to properly investigate grievances filed by six residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #3, who was cognitively intact and required minimal assistance with ADLs, filed a grievance about a conversation with the DNS that was perceived as curt and dismissive. However, the grievance lacked documentation of an investigation, including statements from the DNS or further input from the resident. Similarly, Resident #51, who was also cognitively intact and required extensive assistance with ADLs, filed a grievance about long wait times for call bell responses, but the grievance lacked details about the incidents and did not include interviews or statements from the resident or nursing staff. Resident #588, who was cognitively intact and required assistance with ADLs, filed a grievance about feeling rushed by a Nurse Aide, but the grievance lacked an investigation into the date of occurrence and the activity being performed. There were no interviews or statements from the resident or the NA. Resident #52, who was cognitively intact and required assistance with ADLs, also filed a grievance about long wait times for call bell responses, but the grievance lacked documentation of an investigation, including when the incident occurred and how long the wait was. The grievance form noted that the call bell was functioning properly, but there was no further documentation of the resident's concerns or resolution. Resident #12, who was moderately cognitively impaired and required assistance with ADLs, had a grievance filed on their behalf regarding the approach of a NA. The grievance lacked an investigation into the date of occurrence and the NA's approach, with no interviews or statements from the resident, NA, or nursing staff. The facility's grievance policy required the Social Service Director or designee to review concerns and involve other departments as appropriate, but the grievances reviewed lacked complete investigations and documentation, as confirmed by SW #1.
Failure to Prevent Elopement Due to Wander Guard System Malfunction and Inadequate Supervision
Penalty
Summary
A resident with severe dementia, frontotemporal neurocognitive disorder, and anxiety was identified as being at risk for elopement, with a wander guard device in place and safety checks scheduled every fifteen minutes. The resident's care plan included interventions such as checking the wander guard doors for appropriate settings, daily function checks of the device, and redirecting the resident when exit-seeking behavior was observed. Despite these measures, the resident was able to leave the building unsupervised when a visitor held the door open, and the wander guard alarm did not activate as expected. On the day of the incident, the resident was last seen in the hallway and was not exhibiting exit-seeking behavior according to staff interviews. However, the resident was later found walking in the parking lot by a nursing assistant who was on break. The wander guard device, which should have triggered an alarm and locked the door, failed to do so when the door was already open. Maintenance staff confirmed that the system was supposed to alarm and lock the door when a resident with a wander guard approached, but this did not occur during the incident. The failure of the wander guard system to function as intended, combined with the lack of direct supervision at the exit, allowed the resident to leave the building unsupervised. The incident was documented in the clinical record and facility reports, and interviews with staff confirmed that the required supervision and safety measures were not effective in preventing the resident's elopement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Plainfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Maria Nursing And Rehabilitation Community | 0.2 mi | ★★★★★ | 4 | 0 |
| Pierce Memorial Baptist Home, Inc. | 7.3 mi | ★★★★★ | 6 | 0 |
| Davis Place | 9.1 mi | ★★★★★ | 2 | 0 |
| Douglas Manor | 12.7 mi | ★★★★★ | 7 | 0 |
| Alpine Nursing Home Inc | 13 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.