Piatt County Nursing Home

Inspectors wroteBased on interview and record review the facility failed to supervise a resident during a nebulizer treatment, resulting in the resident falling from bed and sustaining a right hip dislocation. This failure affects one of three residents (R77) reviewed for falls on the sample list of 31. Findings Include: The facility's Falls and Fall Risk Managing policy dated January 2026 documents facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The facility's Administering Medications Through a Small Volume Nebulizer policy dated January 2026 documents the purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. [...]

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to label insulin, eye drops, and nose spray containers with the date opened for three of eighteen residents (R24, R33, R46) reviewed for medication administration on a sample list of 39. B. Based on observation, interview, and record review the facility failed to discard expired insulin for two of eighteen residents (R3, R68) reviewed for medication administration on a sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to use required personal protective equipment during the transfer of a resident on contact isolation and failed to prevented cross contamination during incontinence care and urinary catheter care for three of four residents (R26, R68, R76) reviewed for infection control on the sample list of 39. Findings Include: 1. R26's Physician Order dated June 2025 documents R26 is to be on contact isolation related to Methicillin-Resistant Staphylococcus Aureus (MRSA) of the foot. On 6/17/25 at 8:45 AM V8 Certified Nurse's Assistant (CNA) and V18 CNA transferred R26 using a full mechanical lift. R26 was on contact isolation for Methicillin-Resistant Staphylococcus Aureus (MRSA) of the right foot. Neither V8 nor V18 wore gowns during the transfer. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignified quality of life for one of one resident (R68) reviewed for dignity on the sample list of 39. Findings Include: The facility's Quality of Life - Dignity policy revised in 2024 documents each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff should always treat resident with respect and dignity. Treating with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity are prohibited. Staff should promote dignity and assist residents as needed by promptly responding to a resident's request for toileting assistance (incontinence care). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain call lights within reach for one of one resident (R68) reviewed for call lights on the sample list of 39. Findings Include: The facility's Call Light Policy dated October 2010 documents when residents are in bed or confined to a chair staff are to make sure the call light is within easy reach of the resident. R68's Medical Diagnoses List dated June 2025 documents R68 is diagnosed with Diarrhea, Legal Blindness, Age-related physical debility, and Depression. R68's Minimum Data Set, dated [DATE] documents R68 has some cognitive impairment, uses a wheelchair, is always incontinent of bowel and bladder, and is dependent on staff for toileting hygiene and transfers. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a notice of bed hold to a resident being discharged to a local hospital. This failure affects one resident (R11) out of one reviewed for hospitalization on the sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to transmit minimum data set resident assessments for significant change in status, and discharge, in the required time frame. These failures affect one resident (R5) out of one reviewed for minimum data set transmissions on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to prevent an injury by failing to ensure a bed was in a low position for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a laceration to the right forearm, a hematoma, and spinal fracture which required emergency medical treatment.

Inspectors wroteBased on the interview and record review, the facility failed to provide safe and effective supervision during a total body mechanical lift transfer to prevent a traumatic fall. This failure resulted in R1 falling from R1's transfer sling, striking R1's head on an adjacent bedside table, and landing on the floor, resulting in a collarbone fracture and scalp laceration requiring emergency medical treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to report repetitive instances of verbal and physical abuse of a resident (R45) by V13 Certified Nurse's Assistant and failed to report a resident to resident physical altercation to the facility's Administrator. These failures resulted in V13 having continued access to R45 in which V13 provided direct cares and in the further instances of verbal and physical abuse of R45 by V13. As a result of this abuse R45's hands and chest were bruised and R45 displayed emotional symptoms of residual harm as evidenced by flinching(making sudden startled movements) and increased behaviors with cares. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to be free from physical and verbal abuse by staff. R45, who resides on the dementia unit, was subjected to physical and verbal abuse on three separate occasions by V13 Certified Nurse's Assistant. R45's hands and chest were bruised, R45 was fearful showing emotional symptoms following the incidents as evidenced by increased behaviors with cares, making more sudden abrupt startled movements when approached by caregivers. These failures affect one (R45) of six residents reviewed for abuse on the sample list of 47. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/9/24 when V13 Certified Nurse's Assistant verbally abused R45 during a shower, V13 was suspended from work 3/13/24. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and maintain Certified Nursing Assistant (CNA) required twelve hours of inservice training per year to ensure continued competence. This failure has the potential to affect all 82 residents residing in the facility on the sample list of 47.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow it's abuse prohibition policy by failing to report allegations of abuse to the facility Administrator and prevent further resident abuse. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. These failures have the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit.

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of one (R57) of four residents reviewed for dignity in a sample list of 47 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide access to a hand washing sink for two residents (R21, R12) of 18 residents reviewed for accommodation of needs in a sample list of 47. Findings Include: 1. R21's electronic health record diagnosis list, printed on 4/3/24 at 3:05 PM, documents the following diagnoses: Chronic Obstructive Pulmonary Disease, History of Falling, Right Knee Pain, Abnormal Gait and Mobility, Unsteadiness on Feet, Neuropathy, Muscle Weakness, and Anxiety Disorder. R21's Minimum Data Set, dated [DATE] documents R21 is cognitively intact and uses a wheelchair for mobility. On 4/2/24 at 4:00 PM, R21 stated I have to use the sit-to-stand lift to go to the toilet and it's tight in there, but we manage. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent falls by ensuring a residents personal safety alarm was in working order, using an inappropriate sized mattress on a residents bed and failed to ensure a residents fall interventions were in place. This failure affects three (R19, R35, and R27) of five residents reviewed for falls on the sample list of 47.

Inspectors wroteBased on observation, interview, and record review the facility failed to support the appropriate use of psychopharmacologic medications for residents, failures include: completing residents' psychotropic medication assessments, determine the cause of residents' behaviors considering nonpharmacological interventions, providing parameters for the use of as needed (PRN) antianxiety medication, and providing a rational for duplicative therapy nor required gradual dose reductions for residents receiving psychotropic medications. These failures affects two (R19, R28) of six residents reviewed for psychotropic medication use on the sample list of 47.

Inspectors wroteBased on interview and record review the facility failed to implement antibiotic stewardship practice for residents by ordering prophylactic antibiotics. This failure affects two residents (R60, R35) reviewed for antibiotic stewardship on the sample list of 47. Findings Include: R35's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Tablet 250 MG (Cephalexin) Give 1 tablet by mouth one time a day for Urinary Tract Infection. This order is documented as initiated 6/17/23 and has been given continually since that date. R35's March Medication Administration Record (MAR) documents (R35) was given Macrobid Oral Capsule 100 MG 1 capsule by mouth two times a day related to Urinary Tract Infection from 3/3/24 to 3/21/24 . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly perform and complete catheter care, and maintain urinary drainage collection chambers off of the floor. The facility also failed to treat and complete physician ordered recommendations after the development of a penile wound for two of three residents (R53 and R52) reviewed for indwelling catheter use on the total sample list of 39. This failure resulted in R53's penile wound worsening and becoming split from the urethral opening to the scrotal sac area.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify significant weight loss, notify the physician and Registered Dietitian, implement nutritional interventions, complete nutritional assessments, and record nutritional supplement intake for two (R13, R16) of four residents reviewed for nutrition in the sample list of 39. These failures resulted in R13 experiencing an additional significant weight loss of 6.65 % in one month.

Inspectors wroteBased on record review and interview the facility failed to document an investigation of resident's grievances and failed to notify residents of mitigation/resolution of the grievances as outlined in the facility's Grievance policy. This failure affects nine (R14, R57, R42, R62, R69, R23, R17, R60, R61) residents and has the potential to affect all 83 residents residing at the facility. Findings Include: The facility's Grievance Policy dated August 2018 states It is the policy of (the facility) that each resident has the right to voice to the facility or other agency that hears grievances without fear of discrimination or retaliation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food cooking areas. These failures have the potential to affect all 83 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a care plan for urinary catheter, edema, and wounds for three (R52, R45, R16) of 18 residents reviewed for care plans in the sample list of 39.

Inspectors wroteBased on record review and interview the facility failed to identify targeted behaviors, implement interventions, complete assessments, attempt gradual dose reductions and/or justify the duplicity of psychotropic medications for four residents (R52, R53, R66, and R75) of five residents reviewed for psychotropic medications in a sample list of 39 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (R22) was treated with dignity during dining. R22 was one of two residents reviewed for dignity in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the ability to self administer medications and keep medications at the bedside for one resident (R27) reviewed for self administration of medications in the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a sanitary and homelike environment for one (R69) of 24 residents reviewed for homelike environment on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to notify the state agency, local law enforcement, and adult protective services of an allegation of sexual abuse for one of one residents (R7) on the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to provide activities of daily living assistance for shaving for three of 18 residents (R46, R53, R54) reviewed for activities of daily living on the total sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a treatment order upon identification of a wound for one resident (R45) of two reviewed for skin conditions in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to reduce the risk for falls by failing to ensure the wheels on a bed were locked, the mattress on the bed did not slide, and a cushion on a wheelchair did not slide for two (R69) of three residents reviewed for falls on the sample list of 39.

Inspectors wroteFindings Based on observation, interview and record review the facility failed to properly store, change and label respiratory equipment for three of three residents (R44, R52 and R7) reviewed for respiratory care on the total sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to assess for appropriate use of an antibiotic for one resident (R50) reviewed for antibiotic stewardship in the sample list of 39.