Piatt County Nursing Home

In the surveyor’s words

From the most serious findings on record at Piatt County Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, patternF609Apr 9, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Apr 9, 2024

  Based 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. […]

• Actual harm, isolatedF689Jul 29, 2026

  Based 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. […]

• Actual harm, isolatedF689May 5, 2025

  Based 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. Findings include: The facility's Managing Falls and Fall Risk Policy with a revision date of 12/2021 documents that staff will identify and implement relevant interventions to try to minimize serious consequences of falling. R1's Care Plan initiated on 9/3/2019 documents that R1 was at risk for injury related to mobility status. This Care Plan documents that R1 has a history of skin tears, bruises, and a history of falls. […]

• Actual harm, isolatedF689Feb 10, 2025

  Based 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. […]