Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Piatt County Nursing Home during CMS and state inspections, most recent first.
Surveyors found that staff did not label insulin, eye drops, and nose spray containers with the date opened for three residents, and failed to discard expired insulin for two residents. Both the DON and an LPN confirmed that these medications should have been labeled and expired insulin destroyed, as required by facility policy.
Staff did not use required PPE during the transfer of a resident on contact isolation for MRSA, and failed to prevent cross-contamination during incontinence and catheter care for two other residents. CNAs did not change gloves or perform hand hygiene between tasks, and did not follow proper cleaning techniques, resulting in lapses in infection prevention.
A resident with incontinence, legal blindness, and physical debility was left sitting in soiled briefs for an extended period because her call light was not within reach, despite her care plan requiring it. The resident experienced significant discomfort and pain, and staff confirmed the call light should have been accessible and that needs should be addressed promptly.
A resident with legal blindness, diarrhea, and physical debility was found sitting in a wheelchair with a soiled brief and unable to access her call light, which was placed out of reach behind her. The resident reported discomfort and pain from sitting in soiled clothing for an extended period. Staff confirmed the call light was not accessible and acknowledged that the resident's needs were not promptly addressed, contrary to facility policy and the care plan.
A resident was hospitalized, and the facility did not provide the required bed hold notice. The resident, who was cognitively intact, reported not being informed about her right to return or bed hold policy, and staff confirmed the absence of this documentation.
A resident's MDS assessments for significant change in status and discharge with return anticipated were not transmitted within the required timeframe. Staff interviews revealed confusion about transmission timing and a failure to manually designate the assessments as ready in the system, resulting in the missed transmission.
A resident with a history of falls and skin injuries was found on the floor with a laceration, hematoma, and spinal fracture after staff failed to keep the bed in the required low position as outlined in the care plan. Both CNA and LPN confirmed the bed was in a high position at the time of the incident, leading to the resident's injuries and need for emergency care.
A resident with severely impaired cognition fell during a mechanical lift transfer due to inadequate supervision, resulting in a collarbone fracture and scalp laceration. Two CNAs were involved, but the resident was left unsupported, contrary to facility policy requiring two staff members to manage and support during transfers.
Failure to Label and Discard Medications per Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of drugs and biologicals as required by professional standards and facility policy. Specifically, insulin, eye drops, and nose spray containers for three residents were found open without the date of opening labeled on the containers. Observations of medication carts revealed that these medications were in use without the required labeling, despite the facility's policy mandating that all such medications be labeled with the date upon opening. Both the Director of Nursing and a Licensed Practical Nurse confirmed that these items should have been labeled with the date they were opened. Additionally, the facility failed to discard expired insulin for two residents. During the same medication cart observations, insulin vials were found with open dates and expiration instructions indicating they should have been discarded, but they remained in the carts. The facility's policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and the Director of Nursing acknowledged that the expired insulins should have been destroyed by nursing staff.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow required infection prevention and control protocols during the care of three residents. In one instance, two CNAs transferred a resident who was on contact isolation for MRSA of the foot without wearing gowns, despite a posted sign and physician order requiring both gloves and gowns for entry into the room. The Director of Nursing confirmed that the appropriate personal protective equipment (PPE) was not used during this transfer. Another resident with a history of diarrhea, legal blindness, and physical debility was left in soiled incontinence for an extended period, resulting in discomfort and pain. During incontinence care, a CNA used the same soiled gloves to clean the resident's perineal area, assist with repositioning, and handle clean items, without changing gloves or performing hand hygiene between tasks. The CNA acknowledged that gloves should have been changed and hands cleaned between steps, and that clean items should not have been touched with soiled gloves. A third resident with a urinary catheter and a diagnosis of chronic lymphocytic leukemia and urinary tract infection received incontinence and catheter care from a CNA who failed to change gloves or perform hand hygiene between tasks. The CNA also did not follow proper technique for cleaning the catheter and surrounding area, using the same area of a washcloth for multiple strokes and not cleaning the full length of the catheter tubing as required by facility policy. The CNA later confirmed these lapses in infection control practice.
Failure to Ensure Dignified Care and Timely Incontinence Assistance
Penalty
Summary
The facility failed to maintain a dignified quality of life for a resident with multiple medical conditions, including diarrhea, legal blindness, physical debility, and depression. The resident was dependent on staff for toileting hygiene and transfers, and her care plan required that the call light and personal items be kept within easy reach, with prompt responses to requests for assistance. On the day of the incident, the resident's room had a strong foul odor, and the call light was found out of her reach, behind her wheelchair and under the bed covers. The resident, who is partially blind and unable to move her wheelchair independently, reported that she had been searching for the call light because she needed to be changed after a bowel movement that occurred shortly after breakfast. She stated she had been sitting in soiled briefs for an extended period, resulting in significant discomfort and pain, with the soiling spreading to her perineal area, stomach, and back. When staff were alerted, they confirmed the call light was not accessible and apologized, stating they would return with the necessary equipment to assist the resident. During the cleaning process, the resident exhibited pain, and her skin was observed to be very dark red. Staff acknowledged that if the call light had been within reach, the resident would have used it promptly, as she typically does not like to remain in soiled briefs. The staff also confirmed that call lights should always be within reach and that resident needs should be addressed promptly. The failure to provide the resident with access to her call light and timely incontinence care resulted in prolonged discomfort and compromised her dignity.
Failure to Maintain Call Light Accessibility for Visually Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to maintain a call light within reach for a resident diagnosed with legal blindness, diarrhea, age-related physical debility, and depression. The resident's care plan required that the call light and frequently used personal items be kept within easy reach, and that staff respond promptly to requests for assistance. During observation, the resident was found sitting in a wheelchair with a strong foul odor in the room, and the call light was located behind the wheelchair, attached to the side of the bed under the covers, making it inaccessible to the resident. The resident reported not knowing where the call light was and stated she had been looking for it because she needed to be changed, was very uncomfortable, and in pain. She indicated her bottom was burning from diarrhea and that she had been sitting in it since shortly after breakfast. Staff confirmed the call light was not within reach and acknowledged that the resident should not have been left in a soiled brief for an extended period. The facility's policy and the resident's care plan both required that the call light be accessible, but this was not followed, resulting in unmet care needs.
Failure to Provide Bed Hold Notice Upon Hospitalization
Penalty
Summary
The facility failed to provide a required notice of bed hold to a resident who was discharged to a local hospital. Record review showed that the resident was hospitalized from 8/20/24 through 8/26/24, but there was no documentation in the electronic medical record indicating that a bed hold notice was given. During an interview, the resident, who was found to be cognitively intact based on a perfect score on the Brief Interview for Mental Status, stated she did not recall being informed about her ability to return to the facility or that her bed would be held. The administrative assistant confirmed that no bed hold notice was present for this hospitalization event.
Failure to Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments for a resident who experienced a significant change in status and a discharge with return anticipated, within the required timeframe. The MDS assessments for this resident were completed on 5/16/25, but there was no documentation of a transmitted or accepted date for either assessment. According to the Resident Assessment Instrument 3.0 User's Manual, these assessments are required to be transmitted within 14 days of completion. Review of batch transmission reports confirmed that neither assessment was transmitted during the relevant period. Interviews with facility staff revealed a lack of clarity regarding the timing requirements for MDS transmissions. The MDS Assistant was unsure of the requirements, and the Dementia Unit Coordinator confirmed that the assessments should have been transmitted before the date of the survey. The Assistant Director of Nursing explained that the computer system requires manual designation of assessments as ready to be transmitted, which had not been done for this resident. The Director of Nursing acknowledged that the staff failed to mark the assessments as ready, resulting in the missed transmission.
Failure to Maintain Bed in Low Position Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was maintained in the lowest, most appropriate position as required by the resident's care plan and the facility's fall prevention policy. The resident had a documented history of falls, skin tears, and bruises, and the care plan specifically included an intervention for the bed to be kept in a low position when the resident was resting. On the night of the incident, the resident was found on the floor next to the bed with a large laceration on the right forearm, a hematoma on the forehead, and subsequently diagnosed with a spinal fracture. Both the Certified Nurse's Assistant and the LPN who responded confirmed that the bed was in a high position, contrary to protocol and the care plan intervention. The incident report and interviews with staff indicated that the bed was at the hip or waist level of the staff members, which was higher than required. The Director of Nursing confirmed that the low bed intervention had been in place since the resident's admission to reduce injury risk. The resident's Nurse Practitioner stated that the injuries sustained were a result of the fall and that the severity of the injuries would likely have been less if the bed had been in the correct low position. The failure to follow the care plan intervention directly led to the resident's injuries and the need for emergency medical treatment.
Inadequate Supervision During Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide safe and effective supervision during a total body mechanical lift transfer, resulting in a traumatic fall for a resident. The resident, who has severely impaired cognition and is totally dependent on staff for transfers, fell from the transfer sling, striking their head on an adjacent bedside table and landing on the floor. This incident led to a collarbone fracture and a scalp laceration, requiring emergency medical treatment. The incident occurred when two CNAs were conducting the transfer; one CNA was operating the lift while the other was adjusting the wheelchair, leaving the resident unsupported during the movement. The facility's incident report and witness statements indicate that the securing clip from the sling to the lift came undone, causing the fall. The CNAs involved did not have another staff member supporting the resident hands-on during the transfer, contrary to the facility's policy, which requires two trained staff to safely move a resident with a mechanical lift. The policy also specifies that one staff member should manage the lift while the other supports the resident. Despite the facility's training and policy, the lack of adequate supervision and support during the transfer directly led to the resident's fall and subsequent injuries.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Bement. | 7.5 mi | ★★★★★ | 20 | 0 |
| The Haven Of Farmer City | 15.2 mi | ★★★★★ | 15 | 0 |
| Haven Of Champaign | 15.9 mi | ★★★★★ | 14 | 0 |
| Accolade Healthcare Of Savoy | 16.9 mi | ★★★★★ | 23 | 0 |
| Clark-lindsey Village | 19.4 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.