PIATT COUNTY NURSING HOME
Government - City/county
100 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
6/100
#275 of 665 in IL
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Piatt County Nursing Home has received a Trust Grade of F, indicating significant concerns about the facility's operations. It ranks #1 out of 2 nursing homes in Piatt County, but its overall position at #275 of 665 in Illinois suggests there is room for improvement. The facility is showing some positive trends, with a decrease in reported issues from 9 in 2024 to 6 in 2025. However, it has a concerning staffing turnover rate of 60%, which is higher than the state average, and it has been fined $212,924, indicating compliance issues that are among the highest in Illinois. While there are strengths such as an average overall star rating and a focus on improving trends, there are serious weaknesses. Recent inspection findings revealed critical incidents, including repeated instances of physical and verbal abuse of a resident by a staff member, leading to visible emotional distress and injuries. Additionally, there were issues with proper care for residents, such as a urinary catheter not being secured properly and inconsistent documentation of necessary care. Families should weigh both the facility's potential for improvement and these serious concerns when considering care options.
- Trust Score
- F
- In Illinois
- #275/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $212,924 in fines. Higher than 61% of Illinois facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Top 41%
Review needed
9 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 6 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Illinois average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 60%
14pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $212,924
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (60%)
12 points above Illinois average of 48%
The Ugly 31 deficiencies on record
2 life-threatening 2 actual harm
Jun 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain dignified quality of life for one of one resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
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.
R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown, is legally blind, and staff are to place the call light within easy reach, place frequently used personal items within easy reach and respond to requests for assistance promptly. R68 is at risk for neglect and staff should ensure all needs are met while maintaining dignity and quality of life.
On 6/16/25 at 11:05 AM R68's room has a strong foul odor. R68's call light is not within her reach. R68 is sitting in her wheelchair and the call light is behind her wheelchair and attached to the side of the bed under the covers.
On 6/16/25 at 11:05 AM R68 stated she did not know where the call light was but had been looking for it because she has been needing to be changed for a long time and is very uncomfortable and in pain. R68 stated she is partially blind. R68 stated her bottom is burning from diarrhea and she has been sitting in it since shortly after breakfast. R68 stated she cannot control her bowels, but she always has to go after she eats. R68 stated she had diarrhea after breakfast and has been sitting in it ever since. R68 stated the diarrhea has moved up into her perineal area and on her stomach and up her back. R68 stated her bottom is very painful and feels like it is on fire. R68 stated she is very angry and upset with the situation and can't believe that staff left her in her room without her call light. R68 stated if she had her call light, she would've called staff when she knew she was having the bowel movement so they could change her quickly, so she did not have to sit in it. R68 stated she must be lifted with the full mechanical lift to get into bed and she cannot move her wheelchair on her own. R68 stated she hurts so bad and just wants to be cleaned up and not feel so gross. R68 stated the situation is horrible and she feels disgusting.
On 6/16/25 at 11:10 AM V8 Certified Nurse's Assistant (CNA) was called into the room and confirmed R68's call light was not within her reach. V8 apologized and stated she would return with the mechanical lift and another staff member to assist in getting R68 cleaned up. V8 confirmed call lights should be secured within reach of the residents and resident needs are to be addressed promptly.
On 6/16/25 at 11:13 AM both V8 CNA and V9 CNA entered R68's room with the mechanical lift and began to assist R68 in getting cleaned up. During cleaning, R68 jerked in pain and yelled out for V9 to be easy because her bottom is burning. R68's bottom was very dark red in appearance.
On 6/16/25 at 11:30 AM V9 Certified Nurse's Assistant stated if R68 had been given her call light then she would have used it when she felt the need to have a bowel movement. V9 stated R68 is quick to use her call light because she doesn't like to sit in her soiled brief. V9 confirmed she could tell R68 was very upset and she shouldn't have been made to sit in a soiled incontinence brief for so long.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain call lights within reach for one of one resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown, is legally blind, and staff are to place the call light within easy reach, place frequently used personal items within easy reach and respond to requests for assistance promptly. R68 is at risk for neglect and staff should ensure all needs are met while maintaining dignity and quality of life.
On 6/16/25 at 11:05 AM R68's room has a strong foul odor. R68's call light is not within her reach. R68 is sitting in her wheelchair and the call light is behind her wheelchair and attached to the side of the bed under the covers.
On 6/16/25 at 11:05 AM R68 stated she did not know where the call light was but had been looking for it because she has been needing to be changed for a long time and is very uncomfortable and in pain. R68 stated her bottom is burning from diarrhea and she has been sitting in it since shortly after breakfast.
On 6/16/25 at 11:10 AM V8 Certified Nurse's Assistant (CNA) was called into the room and confirmed R68's call light was not within her reach. V8 apologized and stated she would return with the mechanical lift and another staff member to assist in getting R68 cleaned up. V8 confirmed call lights should be secured within reach of the residents and resident needs are to be addressed promptly.
On 6/16/25 at 11:30 AM V9 Certified Nurse's Assistant (CNA) stated if R68 had been given her call light then she would have used it when she felt the need to have a bowel movement. V9 stated R68 is quick to use her call light because she doesn't like to sit in her soiled brief. V9 confirmed she could tell R68 was very upset and she shouldn't have been made to sit in a soiled incontinence brief for so long.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a notice of bed hold to a resident being discharged to a lo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
R11's Census Detail dated 6/18/25 documents R11 was hospitalized starting on 8/20/24 through 8/26/24.
R11's comprehensive Electronic Medical Record did not contain a notice of bed hold provided to R11.
On 6/17/25 at 9:17 AM, R11 stated she had been to the hospital several times for various reasons. R11 further stated she did not remember anyone telling her anything about being able to come back to the facility nor that the facility would hold a bed for her.
R11's Minimum Data Set, dated [DATE] documents R11 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status indicating R11 is cognitively intact and without memory recall problems.
On 6/17/25 at 3:50 PM, V3, Administrative Assistant, stated there was not a bed hold notice for R11 from the 8/20/25 hospitalization.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based 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 ...
Read full inspector narrative →
Based 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.
Findings include:
R5's Minimum Data Set for significant change in status dated as completed 5/16/25 did not document any transmitted or accepted date.
R5's Minimum Data Set for discharge with return anticipated, likewise dated as completed 5/16/25, did not document any transmitted or accepted date.
The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 documents these minimum data sets for R5 are required to be transmitted within 14 days of the completion date.
On 6/17/25 at 1:58 PM, V5, Minimum Data Set Assistant, stated he was not sure about the timing requirements for the Minimum Data Sets as he was new to his position.
On 6/17/25 at 2:00 PM, V19, Dementia Unit Coordinator/ Dementia Unit Minimum Data Set Coordinator, stated in general a facility has 14 days to complete a resident's Minimum Data Set and another 7 days to transmit. V19 stated R5's Minimum Data Sets should have been transmitted before today (6/17/25). V19 further stated the computer system is supposed to select all of the Minimum Data Sets that have been completed since the previous transmission and transmit them all in one batch. V19 reviewed the batch reports for transmitted Minimum Data Sets from 5/11/25 through 5/20/25 and stated neither of R5's Minimum Data Sets were transmitted.
On 6/17/25 at 2:10 PM, V4, Assistant Director of Nursing, stated the Minimum Data Sets are transmitted through a computer system (IQIES) operated from the Centers for Medicare and Medicaid Services. V4 continued to state that someone at the facility needed to manually designate on their computer that R5's Minimum Data Sets were ready to be transmitted so their computer would transmit the Minimum Data Sets, and no one had designated R5's Minimum Data Sets as ready to be transmitted.
On 6/17/25 at 2:16 PM, V2, Director of Nursing/ Minimum Data Set Coordinator, examined her computer screen and stated R5's Minimum Data Sets should have been transmitted by now (6/17/25). V2 further stated she would need to do a correction on R5's Minimum Data Sets and get them transmitted. V2 stated it was facility staff who made an error by not designating R5's Minimum Data Sets as ready to be transmitted. V2 concluded by stating that generally there is a pattern for transmitting the Minimum Data Sets where a facility has 7 days from the assessment reference date to do the physical assessment of the resident, another 7 days to encode the Minimum Data Set, and another 7 days to transmit the Minimum Data Set.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement.
A. Based on observation, interview, and record revie...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures 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.
Findings include:
a. The facility's Storage of Medications Policy dated 2023 documents that all injectable medications, eye drops, nose spray, ear drops, liquid medications shall be labeled with date upon opening containers.
R24's Medication Administration Record (MAR) dated [DATE] documents R24 is receiving Fluticasone Propionate nose spray. R33's MAR dated [DATE] documents R33 is receiving Dorzolamide HCl-Timolol eye drops. R46's MAR dated [DATE] documents R46 is receiving Lantus insulin.
On [DATE] between 3:18 PM and 3:50 PM, the Team One and Team Three medication carts were observed. R24's bottle of nose spray (Fluticasone) was open and did not have an open date on the bottle. R33's bottle of eye drops (Dorzolamide HCL/Timolol) were open and did not have an open date on the bottle. R46's insulin vial (Lantus) was open and did not have an open date on the vial.
On [DATE] at 3:28 PM, V2 Director of Nursing (DON) stated insulin, eye drops, and nasal spray should have the opened date on the container.
On [DATE] at 3:42 PM, V6 Licensed Practical Nurse (LPN) stated insulin, eye drops, and nose sprays should be labeled with the date when opened.
b. The facility's Storage of Medications Policy dated 2023 documents the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.
R3's Medication Administration Record (MAR) dated [DATE] documents R3 is receiving Admelog insulin. R68's MAR dated [DATE] documents R68 is receiving Lantus insulin.
On [DATE] between 3:18 PM and 3:50 PM, Team One and Team Three medication carts were observed. R3's insulin (Admelog) vial had an open date of [DATE] and an expiration date of [DATE]. R68's insulin (Lantus) vial had an open date of [DATE] and instructions to discard after 28 days.
On [DATE] at 11:11 AM, V2 Director of Nursing stated the expired insulins should have been destroyed by the nursing staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to use required personal protective equipment during the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
On 6/17/25 at 9:00 AM V2 Director of Nurses confirmed R26 is on contact isolation related to MRSA of his foot and both V8 and V18 should have been wearing both gloves and gowns during the transfer.
The undated Contact Precautions sign posted on R26's door documents staff must put on gloves and a gown before entering the R26's room.
2. The facility's Diarrhea and Fecal Incontinence policy dated September 2010 documents residents must be cleaned after each episode of incontinence. Disposable items soiled with feces must be handled to prevent contamination of the environment with feces.
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.
R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown related to physical debility and urinary incontinence.
On 6/16/25 at 11:05 AM R68's room has a strong foul odor.
On 6/16/25 at 11:05 AM R68 stated she did not know where the call light was but had been looking for it because she has been needing to be changed for a long time and is very uncomfortable and in pain. R68 stated her bottom is burning from diarrhea and she has been sitting in it since shortly after breakfast. R68 stated she cannot control her bowels, but she always must go after she eats. R68 stated she had diarrhea after breakfast and has been sitting in it ever since. R68 stated the diarrhea has moved up into her perineal area and on her stomach and up her back. R68 stated her bottom is very painful and feels like it is on fire.
On 6/16/25 at 11:13 AM both V8 CNA and V9 CNA entered R68's room with the mechanical lift and began to assist R68 in getting cleaned up. V9 donned gloves and used disposable perineal wipes to clean the bowel movement from R68's perineal area. After cleaning the perineal area, V9 used the same soiled gloves to assist R68 in turning on her side, V9 touched R68's thigh and gown. V9 then preceded to use disposable wipes to clean the bowel movement on R68's bottom. Once cleaned, V9 continue to use the same soiled gloves and touched R68's leg, arm, and clean incontinence brief. At that point, V9 CNA removed her soiled gloves and put on clean gloves however did not clean hands at all in between.
On 6/16/25 at 11:30 AM V9 Certified Nurse's Assistant confirmed she should have changed her gloves after cleaning R68's perineal area and washed her hands or used sanitizer between glove changes. V9 confirmed she should not have touched R68's arm, leg, clothes, and clean incontinence brief with soiled gloves.
3. The Electronic Medical Record under the section Medical Diagnoses dated 6/17/25 documents the primary diagnoses for R76 are Chronic Lymphocytic Leukemia of B-CELL type not having achieved remission and secondary diagnosis for R76 is Infection and Inflammatory Reaction due to indwelling urethral catheter, subsequent encounter and Urinary Tract Infection.
V18, CNA (Certified Nurse Assistant) performed incontinence care for R76 on 6/17/25 at 2:03 PM. V18 washed her hands and placed gloves on. V18 had positioned R76 to do care and R76 had a bowel movement. V18 with the same pair of gloves on touched R76 and positioned him on his side facing the wall so V18 could clean his buttocks area, V18 also pulled the privacy curtain, touch R76's personal items to find disposable wipes, picked up the disposable wipes and placed on end of the bed and V18 also placed a plastic bag on the end of the bed for trash. With the same pair of gloves V18 cleaned R76's buttock's area in order for R76 to be free of bowel movement. V18 then went and picked up a disposable pad and a clean depends with the same gloves on and placed the pad under R76 and positioned the depends next to V18's buttock's area. V 18 then reposition R76 on his back to position him for catheter care. V18 then removed the gloves and put a new pair of gloves on to perform catheter care without washing or sanitizing her hands.
V18 started catheter care for R76, when V18 completed cleaning the shaft of the penis V18 cleaned under the scrotum sack with the same washcloth and not changing the area of the cloth. V18 took a clean washcloth to clean the catheter tubing and went over the catheter tubing twice with the same area of the washcloth and only cleaned about 4 inches of the catheter tubing.
V18 stated upon completion of the catheter care on 6/17/25 at 2:25 PM, I should of changed gloves before I even started to clean R76 up, did not realize I had touched so many things. I did not realize I went over the catheter tubing twice with the same area of the cloth, I thought I flipped the cloth.
The facility's policy titled Catheter Care, Urinary with the revision date of 06/2023 documents under #16 and #17:
16.
For a male resident: Use a washcloth with warm water to cleanse the meatus. Cleanse the glans using circular stokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position.
17.
Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to end of catheter tubing.
Apr 2024
9 deficiencies
2 IJ (1 affecting multiple)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
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 p...
Read full inspector narrative →
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.
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.
The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring.
Findings include:
R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative.
On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb.
The facility's Allegation/Summary conclusion dated 3/19/24 documents on 3/13/24 at approximately 1:45 PM during a team meeting, V16 CNA (Certified Nurse's Assistant) made the comment to the group that V13, CNA was mean to (R45) and suggested that a bruise seen on (R45's) hand was from Where (V13) was holding her down. V7, CNA then added she witnessed an incident the week prior where V13 threatened R45 after R45 became aggressive during care.
On 4/3/24 at 8:37 AM, V9 CNA stated V13's tone was very aggressive with the residents. A couple months ago, on 1/9/24, I was giving R45 a shower. R45 was becoming combative so I asked V13 for help. R45 made a noise and then said, oh poo. V9 stated V13 then got in R45's face and meanly said, Oh Poo! back to R45 and then hissed like a snake in R45's face very aggressively.
On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 CNA and I went into R45's room. V7 stated they were transferring her to bed and changing her. V7 stated they were talking to R45 and we were trying to get R45's shirt off but it wasn't working and she was tensed up. V7 stated V13 then tried to force her to take the shirt off without saying anything. V7 stated this caused R45 to try to fight her and R45 began to punch and scratch V13. V7 stated V13 then grabbed both of R45's wrists and pinned them against her chest and got face to face to R45 and was touching nose to nose and said, I will snap your wrists if you wont's let us get you to bed. I will snap your legs. V7 stated they then hooked her up to the mechanical lift and got R45 in the bed. V7 stated V7 took R45's pants off. V7 stated as they were trying to change R45, V13 kept pinning R45's arms to her chest. V7 stated once they were done V13 took a blanket and threw it on her (R45).
On 4/3/24 at 8:33 AM, V7 CNA stated after the 3/6/24 incident with V13, R45 was scared. V7 stated during the incident R45 appeared scared, her eyes were great big. V7 stated after that, during cares R45 would flinch (making sudden startled movements) and she still does. V7 stated, I really feel like she still remembers and is now more combative.
V16's undated witness statement documents on 3/12/23, V16 CNA was helping V13 CNA with getting R45 up. R45 was hitting at V16's face and V13 then pinned R45's arms to her chest and said stop hitting or I will break your arms.
Attempts were made to contact V16 for interview, however V16 was unable to be reached.
The facility's census sheet dated 4/1/24 documents R45 resides on the Dementia unit.
The facility's daily staffing sheet documents V13 worked on the Dementia unit on 25 occasions between 1/9/24 and 3/12/24.
V13's Employee Termination Form dated 3/19/24 documents, On March 6th (2024), (V13) verbally abused a resident (R45) by using profanity and physically threatened her during care. and On March 13th (V13) held the same resident's hands down hard enough to bruise her hand and wrist, as well as leaving a small bruise on the resident's chest. She also cursed and threatened the resident during this incident.
On 4/3/24 at 12:00 PM, V1 Administrator stated V13 was terminated for the physical and verbal abuse of V13. V1 stated V13 did have bruising as a result of this abuse.
The Immediate Jeopardy that began on 1/9/24 was removed and the deficient practice corrected on 4/4/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance:
1. On 3/13/24, V13 Certified Nurse's Assistant was suspended by V1 Administrator pending an investigation, V13 was terminated from employment on 3/19/24. On 3/22/24, V39 Unit Coordinator was also terminated from employment by V1 Administrator.
2. On 3/19/24, V1 Administrator reported the abuse to the county sheriff's office.
3. On 4/4/24, V2 Director of Nursing updated R45's care plan with new interventions.
4. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when R45 becomes combative during care.
5. On 4/3/24, V30 Social Service Director completed risk of abuse assessments on all residents in the facility.
6. On 4/4/24, V30 and V3 ADON updated care plans for the residents who were newly identified as at risk for abuse.
7. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when residents becomes combative during cares.
8. On 3/13/24, V1 Administrator, V2 Director of Nursing, V30 Social Service Director re-evaluated the abuse policy and procedures.
9. On 3/13/24, 3/14/24, and 4/4/24, V26 Administrative Assistant and V40 Human Resource Specialist re-educated all staff on the facility protocol for reporting abuse, the types and signs of abuse, and the facility's abuse prevention policy and procedures.
10. On 3/14/24, V1 Administrator developed a quality assurance plan to ensure continuing education of all staff on facilities abuse reporting procedure, skills for identifying and preventing abuse, and how to manage an incident of abuse. This process began on 3/14/24, the audit has been completed weekly, on 3/21/24, 3/28/24 and 4/4/24.
11. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing CNA and Nurse education on interventions with residents who are combative or resistant with care.
12. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing compliance with the updating of care plan interventions for residents who are combative with care.
The facility presented an abatement plan to remove the immediacy on 4/4/24 at 2:11PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/24 at 2:41 PM. The facility presented a revised abatement plan on 4/4/24 and the survey team accepted the abatement plan on 4/4/24 at 4:07 PM.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected multiple residents
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 ...
Read full inspector narrative →
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. This failure has 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.
These Failures resulted in an immediate jeopardy.
The Immediate Jeopardy began on 1/9/24 when V16 Certified Nurse's Assistant failed to report an incident of abuse to V1 Administrator after witnessing V13 verbally abuse R45 during a shower. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM.
The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring.
Findings include:
1. R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative.
On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb.
V16's Employee Termination Form dated 3/19/24 documents V13 was terminated on 3/13/24. This form documents that V16 verbally and physically abused R45 on 3/6/24 and physically abused R45 on 3/13/24 in which R45 was bruised.
On 4/3/24 at 8:37 AM, V9 CNA stated V13 was verbally abusive to R45. V9 stated V9 did not report the abuse to V1 Administrator. V9 stated this occurred on 1/9/24.
On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 was physically and verbally abusive to R45. V7 stated V7 did not report the abuse to V1 Administrator because she was scared of V13.
On 4/3/24 at 8:33 AM, V7 CNA stated after the 3/2/24 incident with V13, R45 was scared. V7 stated during the incident R45 appeared scared, her eyes were great big. V7 stated after that, during cares R45 would flinch and she still does. V7 stated, I really feel like she still remembers and is now more combative.
V16's undated witness statement documents on 3/12/23, V16 CNA witnessed V13 physically abuse R45. This statement documents V16 was afraid to say anything about the abuse V16 witnessed.
On 4/3/24 at 12:00 PM, V1 Administrator stated V1 was not aware of the verbal and physical abuse of R45 by V13 that occurred on 1/9/24, 3/6/24, and 3/12/24 because the CNAs who witnessed the abuse did not report the abuse to him. V1 stated the abuse did occur and R45 was bruised as a result.
The facility's staffing sheets document V13 worked on the Dementia unit on which R45 resides on 1/9/24, 1/10/24, 1/15/24, 1/16/24, 1/18/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, 2/3/24, 2/4/24, 2/6/24, 2/7/24, 2/12/24, 2/13/24, 2/17/24, 2/21/24, 2/26/24, 2/27/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/11/24, and 3/12/24 (24 shifts after the first instance of abuse occurred on 1/9/24).
On 4/3/24 at 10:30 AM, V26 Administrative Assistant stated V13 works mostly on the Dementia unit and can provide care to all residents on this unit.
The facility's census sheet dated 4/1/24 documents 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 reside on the Dementia unit.
2. On 4/01/24 at 9:30 AM, R35 stated someone bent her thumb back. R35's left thumb appeared a little bigger then the other.
The facility's Abuse Report dated 4/5/24 documents V1 Administrator was made aware of an allegation of abuse on 4/1/24. This report documents upon investigation, R35 and R69 did have a physical altercation on the evening of 3/31/24. This report documents that the on-call nurse was notified but not V1, Administrator.
On 4/4/24 at 9:41 AM, V1 Administrator stated there was an altercation between R35 and her room mate. V1 stated V1 was not immediately notified of the incident.
The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy also documents that, A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator.
The Immediate Jeopardy that began on 1/9/24 was removed and the deficient practice corrected on 4/4/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance.
1. On 3/13/24, V13 Certified Nurse's Assistant was suspended by V1 Administrator pending an investigation, V13 was terminated from employment on 3/19/24. On 3/22/24, V39 Unit Coordinator was also terminated from employment by V1 Administrator.
2. On 3/19/24, V1 Administrator reported the abuse to the county sheriff's office.
3. On 4/4/24, V2 Director of Nursing updated R45's care plan with new interventions.
4. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when R45 becomes combative during care.
5. On 4/3/24, V30 Social Service Director completed risk of abuse assessments on all residents in the facility.
6. On 4/4/24, V30 and V3 ADON updated care plans for the residents who were newly identified as at risk for abuse.
7. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when residents becomes combative during cares.
8. On 3/13/24, V1 Administrator, V2 Director of Nursing, V30 Social Service Director re-evaluated the abuse policy and procedures.
9. On 3/13/24, 3/14/24, and 4/4/24, V26 Administrative Assistant and V40 Human Resource Specialist re-educated all staff on the facility protocol for reporting abuse, the types and signs of abuse, and the facility's abuse prevention policy and procedures.
10. On 3/14/24, V1 Administrator developed a quality assurance plan to ensure continuing education of all staff on facilities abuse reporting procedure, skills for identifying and preventing abuse, and how to manage an incident of abuse. This process began on 3/14/24, the audit has been completed weekly, on 3/21/24, 3/28/24 and 4/4/24.
11. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing CNA and Nurse education on interventions with residents who are combative or resistant with care.
12. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing compliance with the updating of care plan interventions for residents who are combative with care.
The facility presented an abatement plan to remove the immediacy on 4/4/24 at 2:11 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/24 at 2:41 PM. The facility presented a revised abatement plan on 4/4/24 and the survey team accepted the abatement plan on 4/4/24 at 4:07 PM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of one (R57) of four residents reviewed for digni...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
R57's Minimum Data Set (MDS) dated [DATE] documents R57 as cognitively intact.
R57's Final Incident Report to the State Agency dated 4/3/24 documents R57 reported V19 Certified Nurse Aide (CNA) used the 'F' (expletive) word and it is offensive to women.
On 4/1/24 at 10:00 AM, R57 stated, There is a male CNA (V19) that comes in my room and uses the 'F' (expletive) word like it is okay to say that. (V19) always brings in another female CNA in with him. (V19) says things like 'F*** (expletive) this and f*** (expletive) that' when he talks to the other CNA and when he talks to me. It is very disrespectful. First of all, I do not require two CNA's to help me with anything. Second of all, I do not allow the use of the 'F' (expletive) word from anyone. I have told (V19) not to say that but he continually does.
On 4/3/24 at 10:30 AM, V1 Administrator stated V19 should not use profanity in front of any residents. V1 stated profanity should not be used in resident areas.
On 4/4/24 at 12:00 PM, V19 Certified Nurse Aide (CNA) stated V19 was previously reprimanded for using foul language in front of residents and may have used expletives in the presence of R57.
The facility policy titled 'Quality of Life-Dignity' revised August 2009 documents staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. Demeaning practices and standards of care that compromise dignity are prohibited.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide access to a hand washing sink for two resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. I'd really like to use the sink to wash my hands and face, comb my hair and brush my teeth, I can't get my wheelchair anywhere close to the sink. I like to do as much as I can for myself. The sink is observed to be between a wall and a cabinet and does not have enough space to roll a wheelchair under it. R21 is sitting in a wide wheelchair.
2. R12's electronic health record diagnosis list printed on 4/4/24 includes the following diagnoses: Parkinson's Disease, Unsteadiness on Feet, and Abnormal Gait and Mobility.
R12's Minimum Data Set (MDS) dated [DATE] documents R12 is cognitively intact and uses a walker and wheelchair for mobility.
On 4/2/24 at 11:00 PM, R12 stated his room does not accommodate his needs as he uses a wheelchair and his bathroom is crowded and he can't get to the sink . The sink is observed to be between a wall and a cabinet and does not have enough space to roll a wheelchair under it. R21 is sitting in a wheelchair.
On 4/4/24 at 11:00 AM, V1 Administrator confirmed there is not enough space to wheel a wheelchair up to the sinks in (R12 and R21's) rooms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R27's undated Medical Diagnosis list documents R27's medical diagnoses as Dementia, Abnormalities of Gait and Mobility, Musc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R27's undated Medical Diagnosis list documents R27's medical diagnoses as Dementia, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Osteoarthritis of Knee, Muscle Weakness, Difficulty in Walking and Heart Failure.
R27's Minimum Data Set (MDS) dated [DATE] documents R27 as cognitively intact. This same MDS documents R27 depends on two staff member and a total body mechanical lift for transfers.
R27's Care Plan interventions dated 11/22/23 documents R27 uses a bed alarm, a full mattress at bedside when in bed. This same careplan documents an intervention dated 12/13/22 that R27 utilizes a total body mechanical lift with two staff for transfers.
R27's Fall Risk Assessment documents R27 as a high fall risk.
R27's Nurse Progress Note dated 3/31/2024 at 2:13 AM documents (R27) is awake at 2:00 AM and has been seated near the nurses station since 10:00 PM (3/30/24) because she was attempting to get out of bed and needed closer supervision.
R27's Nurse Progress Note dated 3/31/24 at 7:03 AM documents (R27) was placed in her bed and then changed by (V24) Certified Nurse Aide (CNA) around 4:20 AM this morning (3/31/24). Once (V24) CNA stepped out to grab the total body mechanical lift and seek assistance, (R27) rolled out of bed. (R27) was found on her Left side and it is unclear if she had hit her head or not since it happened while (V24) CNA momentarily stepped out of the room.
R27's Fall Investigation dated 3/31/24 documents R27 was found on the floor of her room after being left alone momentarily on 3/31/24 at 4:40 AM. This same investigation documents (R27) was at the nurses station from 10:00 PM (3/30/31) to 4:20 AM (3/31/24) being supervised due to other attempt to get out of bed earlier in the evening (3/30/24). This same investigation documents R27's call light was within five to ten feet of R27 (at time of fall). This same investigation documents (R27) was placed in her bed, incontinence care was given by (V24) Certified Nurse Aide (CNA) around 4:20 AM on 3/31/24. Care was complete and (V24) CNA left the room to get a second assist for total body mechanical lift to get (R27) up in chair. When (V24) returned, (R27) was on the floor. (R27) stated she was trying to go home . (R27) was observed on her Left side next to the bedside table and it is unclear if she had hit her head. (R27) was confused and unable to determine if she hit her head.
On 4/3/24 at 3:00 PM, V2 Director of Nurses (DON) stated (V24) was assisting R27 to get up for the day just prior to R27's fall. V2 stated R24 had a fall mat in place prior to her fall but V24 CNA removed the fall mat and then left R27's room to retrieve the total body mechanical lift to transfer R27 from her bed to her wheelchair. V2 DON stated The rooms are tight so it would be difficult to bring in the total body mechanical lift prior to removing the fall mat. V2 DON stated V24 CNA could have gotten another person to assist 'but we (facility) just don't have enough staff for that'.
2.) R35's Incident report dated 2/6/24 at 12:30 PM documents R35) was being turned by two CNA's (Certified Nurse's Aides) to right side in bed while providing care. The mattress fell out from under (R35) due to an incorrectly sized frame. The incident report also documents (R35's) bed frame was switched out by maintenance due to equipment needing repair. There is no documented injury to (R35).
On 4/4/24 at 1:00 PM V2, Director of Nursing stated Maintenance took (R35's) Bariatric bed out for repair and put the Bariatric mattress on a regular bed. The mattress was too big and this caused a fall hazard. It was immediately corrected.
Based 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.
Findings include:
1.) R19's nurse's notes written by V4 Licensed Practical Nurse dated 3/10/24 at 2:41 PM, documents R19 was found on the floor laying on her stomach. R19 was noted to have a contusion above the right eyebrow. R19 was sent to the emergency room for an evaluation.
On 4/02/24 at 11:43 AM, V4 stated on 3/10/24 she had just got done with lunch and she heard someone say that someone was on the floor. V4 stated she ran out there and R19 was laying on the floor on her side and the right side of her face was bleeding. V4 stated she sent her our due to her being on a blood thinner.
On 4/2/24 at 11:49 AM, V5 Activity Aide stated R19 fell around 12:45 PM, stated she was on the other side of the dining room. V5 stated R19's chair alarm did not sound.
On 4/2/24 at 11:58 AM, V6 Certified Nursing Assistant (CNA) stated V6 entered the dining room after R19 fell and they found that her alarm was not sounding.
On 4/2/24 at 12:00 PM, V7 CNA, stated upon entering the dining room after R19 fell the alarm was not sounding. The alarm was changed out after that.
On 4/2/24 at 2:42 PM, V2 Director of Nursing stated on the day of her fall her chair alarm did not alarm. A kinked wire caused the malfunction. We used the alarm to notify us when she is getting up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to support the appropriate use of psychopharmacologic med...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's psychotropic medication policy dated 03/2021 states, 2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. 4. The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of environmental or medical interventions can be utilized prior to psychopharmacological medication use. 5. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation.
1.) On 4/01/24 at 12:15 PM, during lunch meal, R19 was lethargic and tearful asking what is wrong with me? R19 was attempting to feed self but unsuccessful causing tearfulness.
On 4/01/24 at 11:39 AM, V44 (R19's family member) stated she feels R19 is overmedicated and as a result, not eating well. V44 states R19 is sleeping all day and night.
R19's PASSAR (Preadmission Screening and Resident Review) dated 2/28/24 documents there no Serious Mental Illness or Intellectual/Developmental Disability.
R19's Electronic Medical Record documents R19 was admitted on [DATE] with the following diagnoses: Depression, Anxiety, Dementia without Behavioral Disturbance, Psychotic Disturbance, and Mood Disturbance. This Medical record documents R19 was admitted to the facility for treatment of a Urinary Tract Infection.
R19's admission orders dated 2/29/24 documents an order for Escitalopram (antidepressant) 20 milligrams by mouth once daily for anxiety.
R19's physician order dated 3/1/24 documents an order for Ativan 0.5 milligrams by mouth as needed every two hours PO as needed for anxiety/restlessness. This order does not include parameters or nonpharmacological interventions that should be utilized prior to it's use.
R19's medical record does not include a psychotropic assessment or that an attempt was made to determine the underlying cause for R19's behaviors for the use of the Escitalopram or Ativan.
R19's physician's order dated 3/3/24 documents an order for Risperidone 0.25 milligrams every morning for anxiety.
R19's psychotropic medication assessment dated [DATE] does not include what nonpharmacological interventions were attempted prior to ordering the Risperidone.
R19's physician order dated 3/21/24 documents an order for Trazodone (antidepressant) 25 milligrams by mouth every night for depression.
R19's medical record does not include a psychotropic medications assessment for the use of the Trazodone or a rational for the duplicative therapy for the use of the Escitalopram and Trazodone.
On 4/02/24 at 1:50 PM, V2 Director of Nursing stated that a psychotropic medications assessment was not completed when R19 admitted to the facility or after the Trazodone was added. V2 stated there are no parameters listed for the use of the Ativan. V2 stated there is no documentation of what nonpharmacological interventions were attempted prior to the use of the psychotropic medications. V2 stated there is no explanation for the duplicative therapy for the antidepressants.
2.) R28's undated Face Sheet documents R28 admitted to facility on 12/10/2018.
R28's Minimum Data Set (MDS) dated [DATE] documents R28 is moderately cognitively impaired.
R28's Physician Order Sheet (POS) dated April 2024 documents R28's medical diagnosis as Huntington's Disease, Bipolar Disease, Anxiety Disorders and Dysphagia. This same POS documents a physician order starting 1/26/21 with no end date listed for Bupropion Hydrochloride (HCL) Extended Release (ER) 100 milligrams (mg) twice daily for Depression. This same POS documents a physician order starting 7/15/23 with no end date for Risperidone 1 milligram (mg) daily for Huntington's Disease and a separate physician order starting 7/14/23 with no end dated for Risperidone 2 milligrams (mg) daily for Huntington's Disease. This same POS documents a physician order starting 8/7/21 with no end date for Trazodone 25 milligrams (mg) daily for Insomnia.
R28's Note to Attending Physician/Prescriber dated 8/2/23 documents (R28) has been receiving Trazodone 25 milligrams (mg) once daily for Insomnia since 11/2019. Dose reduction attempts should be made for sedative/hypnotic medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This same report documents V33 Physician responded by checking a pre-printed response of Condition is not well controlled. Documentation of the specific clinical rational for your declination is required per Centers For Medicare and Medicaid Services (CMS).
R28's Note to Attending Physician/Prescriber dated 9/6/23 documents (R28) has been receiving Bupropion Sustained Release (SR) 100 milligrams (mg) twice daily for Depression since it was increased 1/2021. Dose reduction attempts should be made for anti-depressant medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This same report documents V33 Physician responded by checking a pre-printed response of Condition is not well controlled. Documentation of the specific clinical rational for your declination is required per Centers For Medicare and Medicaid Services (CMS).
The facility was unable to provide documentation of R28's pharmacy recommendation for a gradual dose reduction.
On 4/2/24 at 1:00 PM V2 Director of Nurses stated the facility is supposed to attempt to reduce the dosage of Psychotropic medications. V2 DON stated the facility is unable to provide documentation of any reduction attempts for R28. V2 DON stated the facility discussed this problem at the last Quality Assurance Improvement Plan (QAPI) meeting in March. V2 DON stated We (facility) knew this was a problem, we just had not come up with a plan to try to fix this problem yet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based 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) ...
Read full inspector narrative →
Based 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 . There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R35) has been given these antibiotics. There is no documentation to support (R35) has a physician's order to be evaluated by a Urologist the entire time (R35) has been given these antibiotics.
R60's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Capsule 250 MG (Cephalexin) Give 1 capsule by mouth one time a day related to personal history of Urinary Tract Infections. This medication has been given continually since 6/22/23. There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R60) has been given this antibiotic. There is no documentation to support (R60) has a physician's order to be evaluated by a Urologist the entire time (R60) has been given this antibiotics.
There is no documentation to support the physician ordering antibiotics for R60 nor R35 has been consulted as to the efficacy of prolonged antibiotic therapy without culture and sensitivity.
On 4/3/24 at 3:30PM V2, Director of Nursing stated the Medical Director orders prophylactic antibiotics and I am aware of the guidelines, but we have to follow his orders.
The facility's Antibiotic Stewardship policy dated 1/19/19 states Antibiotic usage and outcome data will be collected and documented using a facility approved surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide Antibiotic Stewardship through the Quality Assurance Process.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based 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 furth...
Read full inspector narrative →
Based 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.
Findings include:
The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy documents the definition of physical abuse as, the infliction of injury on a resident that occurs other than by accidental means. This policy documents the definition of verbal abuse as, the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. This policy also documents that, A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator.
1. R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative.
On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb.
V16's Employee Termination Form dated 3/19/24 documents V13 was terminated for verbally and physically abusing R45 on 3/6/24 and 3/12/24.
On 4/3/24 at 8:37 AM, V9 Certified Nurse's Assistant (CNA) stated V13 was verbally abusive to R45 on 1/9/24 and she did not report it to V1, Administrator.
On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 was physically and verbally abusive to R45 and that she did not report it to V1, Administrator.
V16's undated witness statement documents on 3/12/23, V16 CNA witnessed V13 physically abuse R45 and documents V16 did not report it to V1, Administrator.
On 4/3/24 at 12:00 PM, V1 Administrator stated V9, V7, nor V16 reported the verbal and physical abuse of R45 inflicted by V13 on 1/9/24, 3/6/24, and 3/12/24. V1 stated the Administrator is supposed to be notified immediately of all abuse allegations.
The facility's staffing sheets document V13 worked on the Dementia unit on which R45 resides on 1/10/24, 1/15/24, 1/16/24, 1/18/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, 2/3/24, 2/4/24, 2/6/24, 2/7/24, 2/12/24, 2/13/24, 2/17/24, 2/21/24, 2/26/24, 2/27/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/11/24, and 3/12/24 (16 shifts after the first instance of abuse occurred on 1/9/24).
On 4/3/24 at 10:30 AM, V26 Administrative Assistant stated V13 works mostly on the Dementia unit and can provide care to all residents on this unit.
The facility's census sheet dated 4/1/24 documents 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 reside on the Dementia unit.
2. On 4/01/24 at 9:30 AM, R35 stated someone bent her thumb back last night.
The facility's Abuse Report dated 4/5/24 documents that on 3/31/24 there was a physical altercation between R35 and R69 and that V1 was not notified of this altercation until the next day.
On 4/4/24 at 9:41 AM, V1 Administrator stated there was a physical altercation between R35 and R69 last night (3/31/24). V1 stated no one reported the altercation to him. V1 stated the Administrator is supposed to be notified immediately.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based 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....
Read full inspector narrative →
Based 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.
Findings include:
V20's training record documents, V20's Continuing Education Hours completed for 2023 total 7.00 hours.
V27's training record documents, V27's Continuing Education Hours completed for 2023 total 11.50 hours.
V28's training record documents, V28's Continuing Education Hours completed for 2023 total 11.50 hours.
On 4/04/24 at 10:15 AM, V2 Director of Nursing states V2 is aware of the required Certified Nursing Assistant (CNA) requirement of 12 hours of annual education. V2 indicates V15, Wound Nurse, is responsible for monitoring CNA education and informing those CNA's that are in need of completing education hours. V2 acknowledges V2 and V15 are aware that several CNA's do not have the required 12 continuing education hours for 2023. V2 confirmed V20, V27, and V28 training record documentation for 2023.
The facility's Long Term Care Application for Medicare and Medicaid dated 4/1/24 signed by V1 Administrator documents there are 82 residents residing in the facility.
May 2023
15 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
2.) On 5/08/23 at 9:39 AM R52 was lying in bed. R52's urinary catheter collection bag was touching the floor, and not secured to the bed. R52 stated R52 has had the catheter for several months and it ...
Read full inspector narrative →
2.) On 5/08/23 at 9:39 AM R52 was lying in bed. R52's urinary catheter collection bag was touching the floor, and not secured to the bed. R52 stated R52 has had the catheter for several months and it was inserted after admission. R52's catheter cleaning/care is performed by the Certified Nursing Assistants (CNAs) 3-4 times per week.
R52's Care Plan dated 5/1/23 and R52's May 2023 Order Summary do not document to perform routine catheter care/cleaning. R52's urinary catheter order dated 1/17/23 documents R52's catheter was ordered/inserted due to chronic wounds.
R52's catheter care report dated 1/8/23 - 5/9/23 do not consistently document catheter care as being completed each shift three times daily.
On 5/09/23 at 9:46 AM V32 and V17 CNAs performed R52's catheter care/cleaning. V17 cleansed R52's inner and outer labia with a wash cloth. V17 wiped across the top of the catheter approximately 1/2 inch, near the insertion site. V17 did not wrap the cloth around the catheter and clean the length of the catheter in a downward motion. R52 asked if V17 was going clean R52's catheter. V32 then provided catheter care in the same way as V17. V32 did not clean R52's catheter.
On 5/09/23 at 9:56 AM V17 stated V17 was hired approximately 5 months ago and received training on catheter care. V17 stated cleaning the length of the catheter was not part of the training. V17 confirmed V17 did not clean the catheter during R52's catheter care.
On 5/09/23 at 10:00 AM V2 Director of Nursing stated catheter care is done by the CNAs at least once per shift/three times daily and documented on the catheter care task report. V2 expects the catheter to be cleaned during catheter care. V2 confirmed the urinary drainage bag should be kept off of the floor and hooked on the bedframe.
Based 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.
Findings include:
1) R53's medical record documents the following diagnosis: Retention of Urine, Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms.
On 5/8/23 at 1:26 PM R53's urinary drainage collection chamber bag was laying on the floor at the end of the bed.
R53's medical record did not contain a comprehensive care plan for the use of an indwelling urinary drainage device or a comprehensive care plan after the development of the wound to R53's penis.
R53's medical record documents on 2/8/23, (V10 Wound Physician) here on 2/6/23 to assess wounds. Resident has a urethral split to penis due to foley. Area measures 1x0.5cm with light serous drainage. 10% devitalized tissue, 90% subcutaneous noted. Will apply petroleum jelly to area daily, V10 recommends an urology consult. (V7 Physician) notified, states to continue to monitor.
R53's Wound Evaluation and Management summary completed by V10 Wound Physician documents, on 2/6/23, NON - PRESSURE WOUND PENIS FULL THICKNESS, Etiology - Trauma/Injury
Duration less than 1 day, Wound Size (L x W x D): 1 x 0.5 x 0 cm, Surface Area: 0.50 cm², Exudate: Light Serous, Thick adherent devitalized necrotic tissue: 10 %, Other viable tissues: 90 % (SubQ)
DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 30 days, PLAN OF CARE REVIEWED AND ADDRESSED, Recommendations: Urology consult. Chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now.
R53's Wound Evaluation and Management summary dated 2/13/23, completed by V10 documents Non-Pressure Wound Penis, Full Thickness, Etiology: Trauma/Injury, Wound Size: 1 x 0.5 x 0 cm. Periwound radius: turbid exudate, Exudate: Moderate Serous, Thick adherent devitalized necrotic tissue: 10 %, Other viable tissues: 90 % (SubQ) (subcutaneous), Wound progress: Deteriorated, DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult.
R53's physician order summary documents, Petrolatum Gel (White Petrolatum), Apply to HEAD OF PENIS topically every night shift for urethral split, start date: 2/8/23, discontinue date: 2/14/23.
R53's Treatment Administration Records dated February 2023 documents the completion of physician ordered treatment of Petrolatum Gel from 2/8/23 through 2/14/23.
R53's medical record documents on 2/16/2023 at 2:53 PM, by V5 Physician, Examined residents penis - due to long term foley placement, the urethral opening has elongated and eroded inferlaterally. There also appears to be either a growth on distal posterior foreskin or simple hypertrophy - hard to tell. Have given ok for urology referral.
R53's Wound Evaluation and Management summary's, completed by V10, dated 2/20/23, 2/27/23, 3/13/23, 3/20/23, 3/27/23 document: Non Pressure Wound Penis, Full Thickness, Etiology (quality) Trauma/Injury, Wound Size (L x W x D): 1 x 0.5 x 0 cm. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult.
R53's medical record did not document the initiation or completion of physician ordered recommendation of Petroleum jelly apply once daily from 2/20/23 through 5/7/23.
R53's medical record documents on 4/7/23 at 1:17 PM, Resident unable to go to urology appointment related to unable to fit in the van in chair. (V7) notified that resident's chair will not fit in transport van, Resident had previously used a wheelchair with a high back and had issues with sliding out and leaning to the side. (V7) asked staff to cancel the appointment for resident.
R53's Wound Evaluation and Management summary's, completed by V10, dated: 4/10/23, 4/24/23 and 5/1/23, documents Non Pressure Wound Penis, Full Thickness, Etiology (quality) Trauma/Injury, Wound Size (L x W x D): 1 x 0.5 x 0 cm. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult.
R53's medical record did not document R53's physician recommended Urology appointment was rescheduled after the cancellation of R53's urology appointment on 4/7/23.
R53's medical record documents on 5/8/2023 at 3:21 PM, V3 Registered Nurse wrote to V7 Physician (V10 Wound Physician) recommended a urology consult for penile wound, (R53) was unable to go in the van in current wheelchair. (V10) is still concerned and wants you to take a look at wound or allow him to go to urologist if we can find him a wheelchair he can go in. Please advise. V7 responded on 5/8/23 at 5:03 PM, (R53) really needs to see urology.
R53's medical record documents on 5/8/23 at 9:47 PM, V12 Registered Nurse wrote to V7 Physician, Resident's Foley catheter has been changed 3 times in one week for non-patency. Current Foley size is 18Fr, may we increase to 20Fr? Resident may also benefit from a suprapubic catheter as the shaft of the penis is torn all the way to his scrotum.
R53's Wound Evaluation and Management Summary dated 5/8/23 completed by V10 documents, NON - PRESSURE WOUND PENIS FULL THICKNESS, Etiology (quality) Trauma/Injury, Duration > 83 days, Wound Size (L x W x D): 2 x 0.5 x 0.05 cm, Surface Area: 1.00 cm², Exudate: Light Serous, Other viable tissues: 100 % (SubQ), Wound progress: Deteriorated. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult.
On 5/09/23 at 10:45 AM V3 Registered Nurse stated, I just returned from (medical leave), (R53) developed the (penis wound) when I was off, (R53) had a urology appointment but the wheelchair wouldn't work in the van so it was cancelled. (V10 Wound Physician) wants (R53) to see a urologist, (R53) needs a urethral splint. (R53's) catheter caused the wound.
On 5/09/23 at 1:10 PM V3 RN stated, I found out (R53) admitted to us in January 2023 and from taking a look at the record, (R53) had catheter issues at the other nursing facility he came from, we did not document that we identified the (penile wound) until February 2023. V3 stated, I think the April Urologist appointment was the first appointment that was available for (R53), I was not able to find any further documentation that the appointment has been rescheduled or if (V10) was notified. I saw the order for the Petroleum jelly was stopped on 2/14/23, I have no idea why.
On 5/9/23 at 1:15 PM during wound care observations, R53's penis was fillet opened from the tip of the urethral opening down to the scrotum. The wound bed had light pink tissue. When asked R53's if the penile wound was sore (causing pain), R53 replied yes, more than you know.
On 5/10/23 at 4:00 PM V10 Wound Physician stated, urethral splits are caused from chronic long term catheter use, the friction of the catheter rubbing causes it, they start out as small slits and can get bigger, when patients get these type of things they need to see a urologist. (R53's) was pretty stable for a long time and recently got worse. V10 confirmed R53 needs to be seen by a urologist. V10 stated, patients with these need to have the catheter repositioned frequently and petroleum jelly applied.
On 5/10/23 at 2:00 PM V3 RN stated, the only time we go over (V10's) recommendations with (V7) is if it is medications, otherwise we start the the other recommendations. The petroleum jelly and the urology consult should have been initiated. I spoke to (V9 Licensed Practical Nurse- Wound Nurse) and she said they had applied the petroleum jelly for a few days and it was causing more drainage to the open area, so they discontinued it, I dont know if it was a miscommunication or what, I did not see a follow up or documentation if (V10) had been notified.
On 5/10/23 at 12:00 PM V2 DON stated, catheter bags should be placed on the bottom of the bed rail, not on the floor.
The facility's policy, with a revision date of November 2020, titled Pressure Ulcers/Skin Breakdown - Clinical Protocol documents, Treatment/Management: 1- They physician will authorize pertinent orders related to wound treatments. 2- The physician will help identify medical interventions related to wound management. The wound nurse/designee will initiate a care plan which will include the location/type of area in the problem statement, a realistic goal, and any/all interventions that are pertinent to the treatment and healing of the wound.
The facility's policy, with a revision date of September 2014, titled Urinary Catheter Care documents, Infection Control: 2-b: Be sure the catheter tubing and drainage bag are kept off the floor. Steps in the procedure: 13- With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. 15- For female: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. 17- Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. The following items should be documented in the residents medical record: 1- The date and time that catheter care was given.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify significant weight loss, notify the physician...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's Impaired Nutrition/Unplanned Weight Loss Clinical Protocol revised October 2020 documents the nursing department are responsible for monitoring resident weights. Significant weight loss is identified as a loss of at least 5% in one month, 7.5 % in 3 months, and 10 % in 6 months. The physician will review possible causes of weight loss. Interventions will be implemented to address weight loss. The Dietitian and Physician will determine the resident's diet including if nutritional supplements need to be added. Monitoring weight loss/nutrition includes evaluating the care planned interventions, evaluating the resident's response to the interventions, determine weight monitoring intervals, identifying additional risk factors such as pressure ulcers, fever, or acute illness, and observing/reporting significant weight loss.
The facility's Nutritional Assessment policy revised September 2011 documents nutritional assessments will be conducted upon admission and with changes in condition that include a risk for impaired nutrition. These assessments will be used to develop interventions to address the resident's risk for impaired nutrition. The Dietitian's component of this assessment will include the estimated calorie, protein, nutrient and fluid needs, and if the resident's intake is adequate to meet nutritional needs.
1. R13's Minimum Data Set, dated [DATE] documents R13 has short and long term memory impairment, had a significant weight loss within the last month, and is not on a prescribed weight loss regimen.
R13's Care Plan revised 4/25/23 documents R13 had significant weight loss noted 1/9/23 and 4/5/23. Interventions dated 1/7/22 include to notify the family and physician of significant weight loss, review diet, intakes, disease process, and behaviors to determine cause, and the dietitian should assess the resident annually and as needed to ensure needs are met. R13's Care Plan dated
7/2/19 documents R13 is at risk for nutritional deficit and includes an intervention revised on 5/4/23 that documents the dietitian evaluated R13 on 2/10/23 with no recommendations, on 3/14/23 with no recommendations, and on 4/28/23 with recommendations.
R13's dated 5/10/23 documents R13 weighed 169.2 pounds (lbs.) on 12/1/22, 163.6 on 1/9/23, 153.8 on 1/31/23 (5.64 % loss since 1/9/23), 160 on 2/7/23, 159 on 3/2/23, 156.2 on 3/8/23, 153 on 3/16/23, and 150.4 on 4/3/23 (5.41% loss since 3/2/23). There are no recorded weights again until 5/4/23 when R13 weighed 140.4 lbs (an additional 6.65 % loss since 4/3/23, and a 17% loss since 12/1/22).
There are no documented nutritional assessments after 12/15/22 in R13's medical record. There is no documentation that R13 was assessed by V25 Registered Dietitian between 1/1/23 and 2/9/23, or that R13's physician was notified of R13's significant weight loss noted on 1/31/23. R13's Dietary Notes document on 2/10/23, R13 has an unstageable pressure ulcer of the right heel. R13's weight was stable between 160-170 lbs with decrease to 153 on 1/31/23 and returned to 160 on 2/7/23. R13 was started on a frozen nutritional supplement two days prior on 2/8 (of the prior year). On 3/14/23 R13 receives a frozen nutritional supplement twice daily. R13's wound healed and weight has been stable for 60 days. No nutritional changes were recommended. On 4/28/23 V25 recommended the addition of a nutritional shake twice daily. There is no documentation that V25 assessed R13 after 3/14/23 until 4/28/23 (25 days after R13's significant weight loss noted on 4/3/23).
R13's Nursing Notes document on 4/12/23 R13's significant weight loss was reported to the practitioner with no new orders given. On 5/4/23 the practitioner was notified and gave orders for 60 cc (Cubic Centimeters) of (nutritional supplement) twice daily and obtain weekly weights for one month.
R13's May 2023 Order Summary includes physician orders to administer a frozen nutritional supplement twice daily for weight loss initiated on 2/23/23 and to administer 60 cc of (nutritional supplement) twice daily initiated on 5/4/23. R13's January 2023 through May 2023 Medication Administration Records (MARs) document R13 received a frozen nutritional supplement once daily, that was ordered from 2/8/22 until 2/23/23. The MAR does not document the amount consumed of the 60 cc nutritional supplement initiated on 5/4/23.
There is no documentation that any new nutritional supplements/interventions were implemented to address R13's January weight loss prior to 2/23/23 when the frozen nutritional supplement was increased to twice daily, and then no additional nutritional supplements were implemented to address R13's April 2023 weight loss until 5/4/23 when the nutritional supplement 60 cc was ordered.
On 5/08/23 at 11:54 AM R13 was sitting in R13's room eating. R13's meal ticket documented a frozen nutritional supplement as part of R13's noon meal. R13's meal tray included [NAME] sandwich, peas, potato salad, and cheesecake, and did not contain a frozen nutritional supplement, and R13 had only ate 1/4 of a [NAME] sandwich. On 05/08/23 at 12:06 PM R13's meal tray did not contain a frozen nutritional supplement, and R13 had not ate any more of R13's food, besides the 1/4 sandwich. On 5/9/23 at 12:08 PM V17 Certified Nursing Assistant (CNA) delivered R13's meal tray to R13's room. The meal tray contained a hot dog, cake, bag of chips, and 2 % milk, and did not contain a frozen nutritional supplement. R13's meal ticket included a frozen nutritional supplement. R13's meal tray did not contain a frozen nutritional supplement at 12:21 PM and 12:27 PM.
On 5/9/23 at 12:35 PM V17 stated the frozen nutritional supplements are served by the dietary department with the meal trays. V17 confirmed R13 was not given a frozen nutritional supplement as part of the noon meal. V20 CNA stated if the frozen nutritional supplement is listed on the meal ticket, then R13 should be getting it.
On 5/09/23 at 12:37 PM V19 Licensed Practical Nurse stated (nutritional supplement) is given by the nurses and the amount consumed is recorded on the MAR. The frozen nutritional supplement is served by dietary, and the nurse is responsible for documenting the amount consumed.
On 5/10/23 at 1:00 PM V25 Registered Dietitian stated V25 began employment at the facility in January 2023. The facility sends a weekly list of resident names for V25 to see. The information submitted to V25 does not include the amount of weight lost. V25 does not give any recommendations until V25 rounds at the facility. V25 was not sure what V25 would expect the facility to do to address resident weight loss in the interim until V25 evaluates the resident. V25 stated V25 completes nutritional assessments documented under the assessments section of the electronic medical record. The assessments are completed upon admission, annually, and with any significant changes. V25 confirmed the frozen nutritional supplement is ordered for R13's weight loss. V25 stated V25 evaluated R13 on 2/10/23 and V25 did not order any new interventions since the frozen nutritional supplement was implemented two days prior by the physician. V25 evaluated R13 in March and R13's weight had stabilized. V25 did not evaluate R13 again until 4/28/23 and recommended the addition of a nutritional shake twice daily. V25 stated V25 did not receive notification in April of R13's significant weight loss until 4/28/23. Additional supplements may have prevented R13's weight loss and confirmed not receiving the frozen nutritional supplement may have affected R13's weight. V25 stated if residents are trending weight loss V25 would expect the facility to follow their weight monitoring policy. In the past V25 has made recommendations to monitor weights weekly, but V25 recently stopped doing that because V25 wasn't sure it was something V25 should be doing.
On 5/09/23 at 3:36 PM V2 Director of Nursing stated weights are obtained monthly unless otherwise ordered. If the resident triggers for a significant weight loss then we notify the physician and dietitian. V25 rounded on 4/26 and 4/28/23 during April. Per R13's care plan, V25 evaluated R13 on 2/10/23 with no new recommendations, 3/14/23 with no new recommendations, and on 4/28/23 with the recommendation to add nutritional shakes twice daily. V2 reviewed monthly dietitian reports and stated V2 did not see documentation that R13 was evaluated by a dietitian in January 2023. On 5/1/23 we increased the frozen nutritional supplement and stopped the shakes due to R13 not liking the shakes. The nurses are responsible for documenting the amount consumed of each supplement. On 5/10/23 at 10:25 AM V2 stated we ran a weight report on 1/24/23 and R13 did not flag for weight loss at that time. The next weight report was not done until 2/16/23 and R13 triggered a significant weight loss. V2 stated weight reports are only done on a monthly basis and that is how R13's significant weight loss on 1/31/23 was missed. There is no documentation that R13's January significant weight loss was reported to the physician and dietitian, and confirmed there were no new nutritional interventions implemented until February 2023. R13 had a significant weight loss on 4/5/23 and V25 did not evaluate R13's weight loss until 4/28/23. There were no new nutritional interventions implemented in March or April until 4/28/23. On 5/10/23 at 1:28 PM V2 stated nutritional assessments should be completed quarterly, annually, and with any significant changes including significant weight loss. V2 confirmed R13's medical record does not document a nutritional assessment was completed after December 2022.
2) R16's physician order summary documents, Mighty Shakes Sugar Free with meals for skin support, start date: 11/15/2022.
R16's wound evaluation and management summary dated 5/8/23 documents Moisture Associated Skin Damage to Sacrum, 2 centimeters by 2 centimeters by 0.3 cm.
R16's Dietary Meal ticket documents, Supplement: Might Shakes- No sugar.
On 5/8/23 at 12:17 PM R16's lunch meal tray was on R16's over the bed table in front of R16. The tray contained a [NAME] Sandwich, Peas, Salad in a cup, cheesecake, milk and tea. There was no might shake on R16's tray.
On 5/9/23 at 11:53 AM R16's lunch meal tray was on R16's over the bed table in front of R16. The tray contained chicken, rice, turtle cake, milk and tea, There was no mighty shake on R16's tray.
On 5/9/23 at 11:54 AM V11 Dietary Aide stated, we give the mighty shakes if someone has an order, we sent the mighty shakes out on the hall trays if they eat in their room.
On 5/10/23 at 12:00 PM V2 DON stated, dietary serves mighty shakes and nurses should follow up if (the resident) received them and how much they drank.
R16's care plan documents R16 has potential for Nutritional Deficit related to history of Colitis, Diverticulitis, Gastro Esophageal Reflux Disorder, weakness. Interventions: Serve Nutritional supplements as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based 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 sam...
Read full inspector narrative →
Based 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.
Findings include:
The Resident Council Meeting Minutes dated 4/10/23 document residents had concerns about Certified Nursing Asssistants (CNAs) using their cellular phones in the dining room during meal times.
On 05/09/23 at 12:13 PM V26 CNA was sitting with R22 in the assisted dining room. R22 had R22's meal tray. V26 was typing on V26's personal cellular phone.
On 5/9/23 at 3:26 PM V2 Director of Nursing stated employees are not to be using cellular phones when assisting residents. We have one CNA, V26, who we have repeatedly talked to about cellular phone usage.
The facility's Quality of Life- Dignity revised August 2009 documents: Residents shall be treated with dignity and respect at all times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based 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 ...
Read full inspector narrative →
Based 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.
Findings include:
R27's medical record does not document an order for petroleum jelly treatment or to self administer Tums. There is no completed assessment in R27's medical record for the ability to self administer medications. R27's care plan revised on 3/26/23 does not document R27 may keep medications at the bedside and self administer medications.
On 5/8/23 at 9:43 AM there was a bottle of Tums 1000 mg tablets and jar of petroleum jelly on R27's overbed table. On 5/9/23 at 12:22 PM the Tums and petroleum jelly were on R27's overbed table. R27 stated R27 applies the petroleum jelly to dry skin and takes the Tums as needed.
On 5/09/23 at 12:30 PM V2 Director of Nursing (DON) stated residents have to have a physician's order to self administer medications and keep medications at the bedside. V2 confirmed R27 does not have an order to self administer medications/keep medications at the bedside. V2 instructed V4 Assistant DON to get an order for Tums and petroleum jelly to be kept at the bedside and to remove the medications from R27's room until the orders are received.
The facility's Administering Medications policy dated January 2021 documents residents may self administer medications if the physician and interdisciplinary team has determined the resident has the capacity to self administer medications safely. Medications may be kept at the bedside if there is a physician's order, a completed self-administration assessment, and care plan for the self administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based 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 o...
Read full inspector narrative →
Based 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.
Findings include:
On 5/08/23 at 10:50 AM, R69 stated they don't empty his urinal. R69's urinal was half full of urine and was sitting on the bedside table next to a banana and granola bar. R69 stated I wish there was another spot to put that. On 5/08/23 at 1:45 PM, R69's urinal was sitting on the bedside table. R69's urinal was a quarter full of urine. R69's water pitcher was sitting next to the urinal.
R69's care plan dated 4/12/22 documents R69 had deficits in Activities of Daily living due to Parkinson's disease.
On 5/10/23 at 12:43 PM, V2 Director of Nursing stated the staff should be emptying R69's urinal and ensuring it is not placed by food or water.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based 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)...
Read full inspector narrative →
Based 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.
Findings include:
On 5/08/23 at 11:50 AM, R7 stated a Certified Nurse's Assistant (V27) stroked his penis a couple times in the shower room before the water was even on. R7 stated V27 no longer gets to work on R7's hallway. R7 stated the Administration of the facility has talked to him about it.
On 5/8/23 at 1:13 PM, V1 Administrator stated a concern was brought to me that V27 had touched R7 inappropriately in the shower. V1 stated V1 interviewed V27 along with V16 (Social Service Director) and R7 stated he didn't have any problems. V1 stated then I asked R7 outright if he had a sexual encounter with a V27 in the shower room and he said yes it was with V27, so I asked what happened and he said that V27 stroked his penis twice while washing him and it made him feel uncomfortable. V1 stated V27 told me it happened 4 to 6 months ago and that V27 didn't have a lot of details. V1 stated, everyone I talked to stated that V27 doesn't want male caregivers and he makes comments to the female staff. V1 stated my initial interview with him was 2/24/23.
V1's handwritten notes dated February 24th documents, an initial concern that R1 was making comments to a Certified Nurse's Assistant (V17) that V27 was touching R7 in the shower. These notes document an investigation but this note does not document that the state agency, local law enforcement, or adult protective services was notified.
On 5/11/23 at 9:43 AM, V1 Administrator stated that he did not notify the state survey agency, the local law enforcement, or the Ombudsmen of the allegation of sexual abuse made by R7 on 2/24/23.
The facility's Policy and Procedure Regarding Abuse and Neglect with a revision date of 2/2021 documents, 33. If the incident involves alleged abuse, neglect or incident of unknown origin, the incident will immediately be reported to the Administrator and the Administrator shall provide the Illinois Department of Public Health with the initial notice of the alleged abuse, neglect, or incident of unknown origin by telefaxing to the Department a copy of report of the incident completed immediately after the incident becomes known. This policy also documents, 76. If you have reasonable suspicion that a crime has occurred against a resident or person receiving care at this facility, Federal Law requires that you report your suspicion directly to both law enforcement (number) and the state survey agency (number).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide activities of daily living assistance for shavi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
1) On 5/8/23 at 10:40 AM R46 was sitting up in wheelchair in room, R46 had stubble covering R46's bilateral cheek area, upper lip and chin area. R46 stated, I shave myself, they give me the stuff, I am not sure when I did last. On 5/9/23 at 10:00 AM R46's continued to have stubble covering R46's cheek area, upper lip and chin areas.
R46's care plan documents, R46 has activities of daily living deficits related to Congestive Heart Failure, Diabetes, Obesity, Anemia, Chronic Kidney Disease, Anxiety and Depression.
R46's MDS (Minimum Data Set) assessment dated [DATE] documents, R46 requires supervision with set up help for personal hygiene.
2) On 5/8/23 at 10:36 AM, R53 was lying down in bed, R53 had long stubble covering R53's bilateral cheek area, upper lip and chin area. R53 stated I need shaved, my electric razor is broken and my son was going to get a new one, they (Staff) help me shave now. On 5/9/23 at 11:00 am R53 continued with long facial stubble covering R53's cheek, upper lip and chin areas.
R53's care plan documents, R53 has ADL deficits related to diabetes, poliomyelitis, hypertension, osteoarthritis, A-fib, Congestive Heart failure. Interventions: Grooming/Oral Care Program: Explain task, provide brushing supplies (mouth swabs, mouthwash, water, cup and basin). Staff to set up supplies cue/assist to begin brushing. Cue/assist to rinse. Document participation, assess progress monthly.
R53's MDS assessment form dated 3/16/23 documents, R53 requires extensive assistance of one staff member for personal hygiene.
3) On 5/8/23 at 11:49 AM R54 was sitting up in wheelchair in dining room. R54 had a goatee. R54 also had stubble covering R54's bilateral cheek areas.
R54's MDS dated [DATE] documents R54 requires extensive assist of one staff member for personal hygiene.
R54's care plan documents, R54 has ADL deficits related to Cerebral Vascular Accident with right sided weakness, Diabetes, Congestive Heart Failure, Anxiety, Depression and Spinal Stenosis.
On 5/9/23 at 10:34 AM V5 Certified Nursing Assistant and V6 CNA stated R54, R46 and R53 need assistance with shaving, either full shaving or setting up supplies for them for shaving and assisting as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based 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 samp...
Read full inspector narrative →
Based 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.
Findings include:
On 5/08/23 at 11:35 AM there was a dressing on R45's forearm dated 5/6/233. R45 stated the wound started a few weeks ago as a dime size and is getting bigger. R45 was not sure what caused the wound. R45 stated the nurses didn't start changing the dressing regularly until a few days ago. On 5/10/23 at 11:01 AM V30 Licensed Practical Nurse administered R45's wound treatment. R45 had a large, circular, pink, moist wound to the right forearm.
On 5/09/23 at 3:07 PM V3 Infection Preventionist stated R45 did not know what caused the wound. Initially we thought R45 scraped R45's arm on the full mechanical lift sling, like an abrasion. V10 Wound Physician took a biopsy of the wound and thinks it may be skin cancer. V3 stated V3 was the first person to document on the wound.
R45's Skin & Wound Evaluation dated 4/28/23 documents R45 has a new abrasion to the right forearm that measured 2.9 centimeters (cm) long by 2.6 cm wide. There is no documentation that a treatment order was initiated for this wound prior to R45 being evaluation by V10 on 5/1/23.
R45's Wound Evaluation & Management Summary dated 5/1/23 completed by V10, documents R45's non-pressure related wound measured 4 cm wide by 4 cm long by 0.05 cm deep. A petroleum dressing was ordered to be applied three times weekly.
On 5/10/23 at 10:25 AM V2 Director of Nursing stated a treatment order should be initiated when a wound is identified and until V10 assesses the wound. V2 confirmed R45 did not have a treatment ordered for the right forearm wound prior to 5/1/23.
The facility's Care of Skin Tears- Abrasions and Minor Breaks policy revised September 2013 documents to notify the physician, obtain a treatment order, and document in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to reduce the risk for falls by failing to ensure the whe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
R69's care plan dated 4/20/22 documents R69 is at risk for injury related to Parkinson's Disease. R69's fall risk assessment dated [DATE] documents R69 is at high risk for falling.
On 5/8/23 at 11:30 AM, R69 was sitting on the edge of his bed. R69 stated his wheelchair is not comfortable and the cushion slides. R69 stated my mattress slides around on bed frame too. R69 stated the wheels on my bed are not locked. R6 stated, I am afraid I will fall. At that time, the head of the bed was not locked and could easily move. The mattress was overhanging the bed frame by half a foot and easily slid around on the bed frame. The cushion in R69's wheelchair slid very easily across the seat.
On 5/10/23 at 12:40 PM, V2 Director of Nursing stated the beds should always be locked and stated V2 would have the mattress and cushion secured.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
3.) On 5/8/23 at 9:39 AM and 1:39 PM R52 was lying in bed wearing oxygen per nasal cannula at 2 liters/minute. R52's oxygen tubing and humidification bottle was dated 4/29/23.
R52' May 2023 Order Sum...
Read full inspector narrative →
3.) On 5/8/23 at 9:39 AM and 1:39 PM R52 was lying in bed wearing oxygen per nasal cannula at 2 liters/minute. R52's oxygen tubing and humidification bottle was dated 4/29/23.
R52' May 2023 Order Summary documents an order to change oxygen tubing and humidifier bottle weekly. R52's May 2023 Treatment Administration Record documents R52's oxygen tubing was scheduled to be changed on 5/5/23.
On 5/9/23 at 10:00 AM V2 Director of Nursing stated oxygen tubing should be changed weekly.
The facility's undated Oxygen Policy/Procedure documents to change the oxygen cannula/tubing when the humidification bottle is changed.
Findings
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.
Findings include:
1) On 5/8/23 at 10:31 AM and on 5/9/23 at 11:34 AM R44's aerosol generating delivery system (mask and tubing) was lying on R44's night stand in room on top of the nebulizer machine. R44's aerosol generating delivery system (mask and tubing) was not stored in a bag.
R44's physician orders documents, change nebulizer equipment and tubing weekly and place in new bag with name and date, start date: 3/5/21.
On 5/10/23 at 10:50 AM V2 Director of Nursing stated, nebulizer equipment (mask and tubing) should be stored in a bag when not in use.
The facility's policy, with a revision date of February 2021, titled Administering Medications Through a Small Volume Nebulizer documents, Steps in procedure: 29- When equipment is completely dry, store in a plastic bag with the residents name.
2.) On 5/08/23 at 2:14 PM, R7's CPAP (Continuous Positive Airway Pressure) mask was lying on the bedside table directly on top of the surface of the table.
On 5/9/23 at 10:15 AM, R7's CPAP mask continued to lie on the beside table directly on top of the surface of the table.
On 5/10/23 at 12:44 PM, V2 Director of Nursing stated CPAP masks should be placed in a bag when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess for appropriate use of an antibiotic for one resident (R50) r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
R50's May 2023 Order Summary documents an order dated 7/9/21 to administer Azithromycin (antibiotic) 250 milligrams by mouth three times weekly on Monday, Wednesday, and Friday for diagnosis of Chronic Obstructive Pulmonary Disease (COPD). R50's Care Plan revised 9/21/22 documents in the problem category that R50 receives a prophylactic antibiotic for COPD and in the interventions it lists that R50 receives the prophylactic antibiotic to prevent Urinary Tract Infections (UTIs).
R50's Hospital Discharge summary dated [DATE] documents R50 receives Azithromycin three times weekly to prevent bronchitis. There is no documentation that the use of this antibiotic was assessed or re-evaluated for appropriate use.
On 05/09/23 at 2:59 PM V3 Infection Preventionist stated the facility uses McGreer's criteria (infection control resource) to determine appropriate use of antibiotics and V3 notifies the provider if appropriate criteria is not met. R50 receives prophylactic Azithromycin to prevent UTIs and confirmed COPD is not an appropriate diagnosis to warrant the use of an antibiotic. On 5/10/23 at 9:11 AM V3 stated R50 admitted to the facility with the Azithromycin order and it was prescribed to prevent bronchitis. V3 stated prior to yesterday, there was no assessment to evaluate appropriate use of this antibiotic in R50's medical record.
The facility's Antibiotic Stewardship policy dated 1/29/19 documents the facility will closely monitor the use of antibiotics. When antibiotics are prescribed, the order will include the duration for treatment with a start and stop date. The facility will utilize the McGreer's Definition of Infection, and this will also be used to notify the physician. The Infection Control nurse/designee is responsible for reviewing antibiotic use. This policy does not reference the use of prophylactic antibiotics. This policy includes the undated Centers for Disease Control and Prevention brochure titled Get Smart Know When Antibiotics Work, documents: To avoid the threat of antibiotic-resistant infections, the Centers for Disease Control and Prevention (CDC) recommends that you avoid taking unnecessary antibiotics.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based 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 ...
Read full inspector narrative →
Based 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.
Findings include:
The facility's policy, with a revision date of December 2016, titled Care Plans, Comprehensive Person-centered documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8- The comprehensive, person centered care plan will: g- Incorporate identified problem areas. k- Reflect treatment goals, timetables and objectives in measurable outcomes. 10- Identify problem areas, their causes, and developing interventions that are targeted and meaningful to the resident. 13- Assessments of residents are ongoing and care plans are revised as information about the resident and the residents condition change.
1.) On 5/08/23 at 9:39 AM R52 was lying in bed and R52's urinary catheter collection bag was touching the floor, and not secured to the bed. R52 stated R52 has had the catheter for several months.
R52's Care Plan dated 5/1/23 documents R52's urinary catheter use and interventions. There is no documentation that a care plan for R52's catheter was developed/implemented prior to 5/1/23. R52's urinary catheter order dated 1/17/23 documents R52's catheter was ordered/inserted due to chronic wounds.
On 5/9/23 at 3:17 PM V8 Care Plan Coordinator confirmed R52's care plan did not include R52's urinary catheter prior to 5/1/23.
2.) R45's Skin & Wound Evaluation dated 4/28/23 documents R45 has a new abrasion to the right forearm that measured 2.9 centimeters (cm) long by 2.6 cm wide. R45's May 2023 Order Summary documents an order to cleanse R45's right forearm wound, apply a petroleum gauze dressing, and cover with a dry dressing three times weekly.
R45's Care Plan revised on 5/3/23 does not include R45's wound and interventions.
On 5/08/23 at 11:35 AM there was a dressing on R45's forearm dated 5/6/233. R45 stated the wound started a few weeks ago and was the size of a dime. On 5/10/23 at 11:01 AM V30 Licensed Practical Nurse administered R45's wound treatment. R45 had a large, circular, pink, moist wound to the right forearm.
On 5/9/23 at 3:17 PM V8 Care Plan Coordinator confirmed R45's care plan does not address R45's wound.
3.) On 5/08/23 at 11:37 AM R45 had swelling noted to hands and bilateral feet. R45 stated R45 takes a diuretic and R45's edema/swelling has not gotten any worse. On 5/09/23 at 10:43 AM R45 was sitting in a recliner and R45's feet were not elevated. R45's feet, ankles, and calves were swollen.
R45's May 2023 Order Summary documents to administer Furosemide (diuretic) 60 milligrams (mg) daily since 11/2/22 and administer Spironolactone 50 mg daily since 8/30/22. R45's Care Plan revised 5/3/23 does not document R45's edema and interventions.
On 5/09/23 at 3:17 PM V8 Care Plan Coordinator confirmed R45's care plan does not include R45's edema.
4) On 5/8/23 at 12:15 PM R16 was lying in bed with a urinary drainage bag attached to the bed rail, with dark yellow urine in the drainage bag.
R16's physician orders document Change Foley (indwelling urinary drainage device) catheter, #20French/30 cubic centimeters every 30 days and as needed, start date: 1/23/23.
R16's medical record did not contain a comprehensive care plan for the use of an indwelling urinary drainage device.
On 5/10/23 at 2:00 PM V2 DON confirmed R16 did not have a care plan for indwelling catheter use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
4.) R52's Discontinued Order Summary dated 5/11/23 and May 2023 Order Summary document orders to administer Seroquel (antipsychotic) 50 milligrams (mg) by mouth daily since 2/7/22. There is no documen...
Read full inspector narrative →
4.) R52's Discontinued Order Summary dated 5/11/23 and May 2023 Order Summary document orders to administer Seroquel (antipsychotic) 50 milligrams (mg) by mouth daily since 2/7/22. There is no documentation that a gradual dose reduction of the Seroquel was implemented.
R52's Care Plan revised 2/12/23 documents R52 receives Seroquel 50 mg daily and includes an intervention for the interdisciplinary team to review for gradual dose reduction if appropriate.
R52's Nursing Notes document on 2/16/23 an order was received to reduce R52's Seroquel to 25 mg daily, and R52 refused to have R52's Seroquel decreased.
The Note To Attending Physician/Prescriber dated 1/31/23 documents R52 has received Seroquel 50 mg daily since February 2022, and the pharmacy recommended a reduction to 25 mg daily. This note is signed by the practitioner on 2/6/23 and notes that R52 declined the reduction on 2/16/23. There is no documented clinical rational by the practitioner as to why the current dose is medically necessary or contraindicated in R52's medical record.
On 5/9/23 at 10:00 AM V2 Director of Nursing stated R52 admitted to the facility on Seroquel for Major Depressive Disorder. R52's behaviors include being tearful and restless. V2 stated there was an order to reduce R52's Seroquel, but R52 refused. V2 confirmed a gradual dose reduction was not attempted. On 5/11/23 at 9:50 AM V2 confirmed R52's pharmacy recommendation to reduce the Seroquel does not document a clinical rational by the practitioner as to why the current dose should be continued and contraindications to reduce the medication.
3) R53's physician order summary documents, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsules (250 milligrams total) by mouth two times a day related to Dementia with other behavioral disturbance, start date: 1/26/23.
R53's medical record documents on 1/26/2023 at 10:48 AM by V7 Physician, Nurses report agitation, yelling, throwing things, turning over nightstand etc. He does have decubitus under treatment and suspected Urinary Tract Infection. Urine specimen being sent for Culture and Sensitivity. Start Bactrim until urine results back, start Depakote 250mg BID for aggression/agitation.
R53's medical record did not contain a psychotropic medication assessment after the initiation of Depakote or a reassessment since the initiation of Depakote on 1/26/23.
R53's Behavior Evaluation Form documents, Behavior Tracking: experiences difficulty sleeping (yelling out at night).
R53's medical record did not contain a comprehensive care plan for the use of Depakote or targeted behaviors being monitored for the use of Depakote with individualized interventions.
On 5/10/23 at 10:25 AM V2 Director of Nursing stated, (R53) has no psychotropic medication assessment because (V8 MDS coordinator) thought since Depakote is an anticonvulsant an assessment does not need to be done, but he is not receiving it for seizure treatment.
Based 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.
Findings include:
The facility's Psychotropic Medication Policy and Procedure dated March 2021 documents to determine underlying causes of behaviors to implement appropriate treatment including environmental, medical, and/or behavioral interventions. The physician should document the rationale and diagnosis for psychotropic use and identify targeted symptoms. Gradual dose reductions will be attempted in two separate quarters and annually thereafter unless clinically contraindicated. The interdisciplinary team will review the use of psychotropic medications quarterly and determine targeted behaviors and adverse effects.
1.) R66's Physician's Order Summary printed 5/10/23 includes the following orders for psychotropic medications: 1. Risperdal (Antipsychotic) 0.5 milligrams. Give 1 tablet by mouth two times a day related to Unspecified Dementia with Behavioral Disturbance (Originally ordered 2/22/22), 2. Seroquel (Antipsychotic) 50 milligrams 0.5 tablet by mouth one time a day related to Unspecified Dementia with Behavioral Disturbance (Originally ordered 5/10/22), and 3. Lexapro (antidepressant) 10 milligrams Give 1 tablet by mouth one time a day related to Other Specific Depressive Episodes. (Originally ordered 3/9/22)
R66's medical record documents psychotropic assessments dated 11/22/22 and 3/15/23. R66's medical record does not contain assessments for the quarters prior to this. R66's medical record does not contain documentation of tracking of targeted resident specific behaviors for R66 or the interventions attempted for behaviors. R66's medical record does not document a justification for the use of duplicative antipsychotic medication.
On 5/10/23 at 1:05 PM, V2 Director of Nursing verified R66's duplicative antipsychotics had not been addressed and that R66 had missing quarterly assessments.
2.) R75's Physician's Order Summary printed 5/11/23 includes the following orders for psychotropic medications: 1. Risperidone (antipsychotic) 0.25 milligrams, Give 1 tablet by mouth two times a day related to Vascular Dementia, Unspecified Severity with Other Behavioral disturbance, 2. Sertraline HCl (Hydrochloride) 50 milligrams, Give 1 tablet by mouth one time a day related to Depression Unspecified.
R75's medical record does not contain documentation of tracking of R75's targeted resident specific behaviors or interventions attempted for behaviors.
On 5/10/23 at 1:00 PM, V16 Social Service Director a verified that she had been tracking diagnoses rather than resident specifics behaviors. V16 stated Social Service is a fairly new roll for me. I was not aware we have to track resident specific behaviors.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based 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 ...
Read full inspector narrative →
Based 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. The policy further states An investigation will commence, comprised of a review of the complaint, interviews with appropriate persons and witnesses, review of the medical record as appropriate, a permitted search of the resident's room and surrounding area, and a root cause analysis of all circumstances surrounding the incident. This will be completed utilizing the Grievance Investigation Form. (The facility) will ensure prompt resolution of all grievances, keeping the resident and his or her representative informed throughout the investigation and resolution process.
The resident census and condition report dated 5/8/23 documents there are 83 residents residing in the facility.
On 5/8/23 at 2:00 PM, a resident council meeting was attended by R14, R57, R42, R62, R69, R23, R17, R60, and R61. R14 stated I don't think V16 (Social Service Director) takes our complaints seriously. We go to her and things never change and we never hear what was done to correct what we complain about. Other residents present either nodded in agreement or commented in agreement with R14's concern.
The meeting was attended by the Long-Term Care Ombudsmen (V31)
On 5/9/23 at 3:00 PM, V16 stated When I get a grievance I just log it into the concern log and up date it as I find out more. I don't fill out a form for every concern.
On 5/9/23 at 3:15 PM, V2 Director of Nursing stated I definitely look into residents' concerns if they come to me or members of the nursing staff. (V16) is the grievance official. I don't fill out a grievance form, but I take care of any concerns as soon as I'm aware.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based 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.
Findings ...
Read full inspector narrative →
Based 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.
Findings include:
On 5/08/23 at 9:11 AM, V13 Assistant Dietary provided a tour of the kitchen where residents food is prepared. During the tour, accumulated dust was covering the vents and the recessed lights cages above the above the cooking range and griddle. Grease and food particles was covering the edges of the fryer. Floating particles of food was floating in the oil in the fryer. The fryer was on. V13 stated it was supposed to be cleaned yesterday and they were getting ready to make chicken strips in the fryer.
On 5/9/23 at 9:54 AM, the dust on the vents and the recessed light cages above the range and griddle was still present.
The resident census and condition report dated 5/8/23 documents there are 83 residents residing in the facility.
Jan 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to maintain resident-shared shower rooms in a clean, comfortable, and sanitary manner. This failure affects all 75 residents resid...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to maintain resident-shared shower rooms in a clean, comfortable, and sanitary manner. This failure affects all 75 residents residing in the facility.
Findings include:
On 1/17/23 between 10:10 am and 11:00 am the resident-shared shower rooms were toured with V6 (Maintenance Director). V6 confirmed the 70's hall shower room had a strong musty odor. The 70's hall shower also had a buildup of a brown thick sticky substance in the floor wall joint corners. There was also caulking peeled off, exposing brown spots. V6 stated, I don't think they used the right caulk when they remodeled this bathroom. The shower definitely looks dirty.
During the same tour of the resident shared shower rooms, the 50's-60's hall shower room smelled musty. The vent in the shower room was filled with dust. Thin openings between the slats of the vent grids appeared clogged. The 50's-60's hall shower had a brown and black mossy appearing substance along the floor-wall joints surrounding the shower floor. V6 stated, This definitely needs addressed. I will be following up with this today.
During the same tour of the resident shared shower rooms, the 40's hall shower room smelled musty. The ceiling of the shower was speckled with brown spots. The vent grid was heavily soiled with dust between slats. The 40's hall shower had a brownish black buildup of a substance that resembled mold. The mold resembling substance was up three inches on the left wall of the shower and into the left corner. V6 (Maintenance Director) stated, That is likely mold.
During the same tour of the resident-shared shower rooms, the 50's hall shower room smelled of a very strong foul musty odor. There was an 'out of order' sign on the shower wall. The 50's shower stall walls and floor had copious amount of black and brown substance resembling mold that extended completely around the four foot by eight foot shower stall. The black brown mold-like substance extended upward two feet. The fixture wall of the shower had a one quarter inch crack in the tile that extended twelve inches. V6 (Maintenance Director) stated, There is no doubt this is mold. I retired from here (facility) after 30 years and came back November 1, 2022 to address these problems. The facility has had a mold problem for a while. The building is old .built in the 1960's. It has problems. I was just informed last week. (V7/Maintenance Worker) brought it (mold in 50's shower room) to my attention. It has mold in the walls and floors. I came over right away, looked at it (shower stall) and closed it down right then.
On 1/17/23 at 11:15 am V12 (Registered Nurse/RN/Infection Control Coordinator) stated, I work all units. The shower rooms on all units have a bad odor of mold. The ventilation system doesn't work well. It is worst in the summer. We have to use the showers to provide showers for all our residents. V12 also stated, The Administrator and Maintenance department know about it and have (known) about it have for probably a year.
On 1/17/23 at 11:20 am V13 (Certified Nursing Assistant/CNA) stated, I have worked here 18 years. Oh yeah, there is moldy smell in every one of our (the facility) showers. You can smell it the most in the 50's hall shower room. I have been complaining for about six months as the mold was growing darker and up from the floor in the showers. I have given showers in this shower (50's hall) within the last couple weeks. It depends on what hall we are working which bathroom we take the resident in for showers. We have been using all of them (shower rooms) until the out of order sign went up the other day (50's hall shower room).
On 1/17/23 at 11:52 am V7 (Maintenance Worker) stated, When I started in October 2022, there was mold in several places in the facility. A previous maintenance staff (V24) told me the facility was remodeling that shower stall (50's hall). I saw how bad it had gotten last week. (V19/Housekeeper) told me. I took a look and saw it was pretty bad. I suspected it was mold but could not confirm it. I went and got (V6/Maintenance Director). (V6) had me take off the shower handle and put up the out of order sign. I am pretty sure it was being used up to that point.
On 1/17/23 at 2:44 pm V24 (Previous Maintenance Worker) stated, I was doing all the remodeling in the facility until November 1, 2022. The heating and air conditioning lines are switched to circulate hot and cold air throughout the facility. Some of the pipes leak condensation and form mold that creates the musty odor throughout resident rooms when (air) switched (cold to hot) over. The ventilation system does not work well. The facility has been aware of these problems the whole year I worked there (in the facility). I would run across mold in every project I worked on. We removed wallpaper off the walls by B nursing station. The walls were covered in black mold. We treated it with bleach and a mold resistant paint. That just covered up the problem. There is mold inside every wall to some degree. All the resident bathrooms I remodeled over the past year had tiles that popped off that exposed more mold. The resident shower stalls, especially the 50's hall, had mold. I was told the remodeling for the 50's hall was going to happen soon after I started a year ago. The delay in getting the products planned to do the remodeling in there was holding up the start of that project.
On 1/17/23 at 4:10 pm R1 stated, The shower rooms stink.
On 1/18/23 at 10:30 am V25 (Housekeeping/Laundry Supervisor) stated, It has been at least six months ago that we started to get mold bad in the shower rooms. There is no ventilation in there. V25 stated, When I saw the 50's (hall) shower room had gotten so bad with mold, I had (V19/Housekeeper) report it to (V7/Maintenance Worker) in maintenance. He (V7) and (V6/Maintenance Director) looked at how bad it had gotten in there and shut the shower room down.
On 1/18/23 at 12:20 pm V5 (Director of Nursing/DON) confirmed all residents receive showers as required twice a week, therefore all residents are affected by the condition and cleanliness of the shower rooms.
On 1/18/23 at 12:25 pm R5 stated, I understand the housekeepers are busy, but it is ridiculous they don't keep the shower room (40's hall) clean. It has a bad odor, and it has crud in the shower. My bathroom does not smell good either. If they cleaned better, I am sure that would make a difference.
On 1/18/23 at 12:30 pm R6 stated, The shower down here (50's hall) is closed. It is about time; it has been growing something in there for months. The odor is really pretty bad.
On 1/18/23 at 12:45 pm R4 stated, I can tell you the shower rooms are all dirty. The one across this hall and the one around the corner. There is some kind of black stuff on the shower floors. I don't stand in there. They put me on a special shower cot. I can see though, and it looks terrible. I am not sure the showers are getting cleaned. It certainly does not look like it.
The facility Daily Census Report printed 01/17/23 documents 75 residents reside in the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 2 harm violation(s), $212,924 in fines, Payment denial on record. Review inspection reports carefully.
- • 31 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $212,924 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Piatt County's CMS Rating?
CMS assigns PIATT COUNTY NURSING HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Piatt County Staffed?
CMS rates PIATT COUNTY NURSING HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Piatt County?
State health inspectors documented 31 deficiencies at PIATT COUNTY NURSING HOME during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 27 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Piatt County?
PIATT COUNTY NURSING HOME is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 100 certified beds and approximately 83 residents (about 83% occupancy), it is a mid-sized facility located in MONTICELLO, Illinois.
How Does Piatt County Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, PIATT COUNTY NURSING HOME's overall rating (3 stars) is above the state average of 2.5, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Piatt County?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Piatt County Safe?
Based on CMS inspection data, PIATT COUNTY NURSING HOME has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Piatt County Stick Around?
Staff turnover at PIATT COUNTY NURSING HOME is high. At 60%, the facility is 14 percentage points above the Illinois average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Piatt County Ever Fined?
PIATT COUNTY NURSING HOME has been fined $212,924 across 3 penalty actions. This is 6.0x the Illinois average of $35,208. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Piatt County on Any Federal Watch List?
PIATT COUNTY NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.