Colonial Health & Rehab Center of Plainfield, LLC

In the surveyor’s words

From the most serious findings on record at Colonial Health & Rehab Center of Plainfield, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689May 19, 2026

  Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure adequate supervision and assistance during transfers. Specifically, staff failed to recognize and respond to signs of increasing transfer instability in the weeks prior to a fall; failed to recognize that Resident #1 was unable to bear weight at the initiation of a transfer and continued the transfer without seeking assistance; left Resident #1 unattended on the floor following a fall with a head strike; and transferred Resident #1 off the floor despite observable signs of significant pain. […]

• Actual harm, isolatedF697May 19, 2026

  Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pain management, the facility failed to manage Resident #1's pain in accordance with facility policy and the resident's care plan. Specifically, licensed nurses failed to reassess pain within one (1) hour after administration of as-needed pain medication on multiple occasions; failed to recognize observable signs of significant pain during post-fall transfers as a change in condition requiring provider notification; and failed to administer pain medication in a timely manner following a fall that resulted in a major injury. […]

• Actual harm, isolatedF689Oct 23, 2025

  Based on clinical record, facility documentation, and facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure resident was transferred safely to prevent an injury. The findings include: Resident #1's diagnoses included dementia and osteoporosis. Physician order dated 9/8/2025 directed assist of two (2) with mechanical lift for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment and was dependent for transfers. The Resident Care Plan (RCP) dated 9/29/2025 identified Resident #1 had and alteration in mobility. […]

• No harm, potential for more than minimal, patternF684Jun 8, 2026

  Based on review of clinical record, facility documentation, facility policy and interviews, for 3 residents (Resident #9, 1 and 50), the facility failed to administer medications and/or monitor blood sugar according to professional standards and physician's orders. For 1 resident (Resident #9) reviewed for medication errors, the facility failed to ensure staff followed the physician's order for Xanax (antianxiety medication) administration after a change in the dose. For 1 of 5 residents (Resident #1) who were reviewed for unnecessary medications, the facility failed to ensure blood glucose monitoring was performed as prescribed by the provider. […]

• No harm, potential for more than minimal, patternF812Jun 8, 2026

  Based on a tour of the Dietary Department, observations, review of facility policy, and interviews, the facility failed to ensure food temperatures were monitored, documented, and maintained in accordance with professional standards for safe food handling. The findings include:Interview and review of food temperature logs with the Food Service Director (FSD) on 6/4/26 at 12:30 PM identified multiple missing food temperature entries. Review of temperature logs dated 5/1/26 through 6/4/26 revealed puree food temperatures were missing for at least one meal on 13 of 35 days reviewed. In addition, no temperatures were documented for cold entree items during the review period. […]