Mattoon Rehab & HCC

Inspectors wroteBased on observation, interview and record review the facility failed to maintain residents' dignity by failing to provide care before ambulation with therapy, for a resident with urine saturated clothes. This failure affected one (R6) of four residents reviewed for incontinence care/dignity on the sample list of six residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (R9, R12, R18) of six residents reviewed for abuse remained free from verbal, mental, and physical abuse. This failure resulted in the loss of dignity and the potential for humiliation and emotional distress for R9, fear and ongoing psychosocial distress for R18, and abusive behavior by R12 toward another resident.

Inspectors wroteBased on interview and record review the facility failed to provide timely responses to resident grievances for three residents (R2, R3, R4) out of four residents reviewed for Activities of Daily Living (ADL) in a sample list of four residents.

Inspectors wroteBased on observation, interview and record review the facility to prevent cross contamination during wound care for one (R1) resident out of three residents reviewed for wound care in a sample list of four residents.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for insulin administration for one (R3) of three residents reviewed for quality of care in a sample of 69. This failure resulted in R3 receiving a dose of insulin via a syringe while simultaneously receiving insulin from an insulin pump, causing hypoglycemia, decline in condition, and hospitalization. This past noncompliance occurred from 4/2/2026 to 4/6/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident shower rooms were maintained in a safe, clean manner and in good repair for two of three shower rooms located on [NAME] Hall and [NAME] Hall. This failure has the potential to affect 64 of 64 residents (R4 and R7 through R69) reviewed for homelike environment in the sample list of 69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from verbal abuse by employees. This failure affected three of five (R2, R4, and R6) residents reviewed for abuse in a sample of six residents.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to complete wound assessments, follow physician's orders, implement infection control during wound care for one of 15 residents (R5) reviewed for wounds in the sample list of 15. These failures resulted in deterioration of R5's wounds and infection that required hospitalization and intravenous antibiotics. B. Based on interview and record review the facility failed to develop and implement interventions for preventing skin tears for one of five residents (R6) reviewed for wounds in the sample list of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately account for and destroy controlled medications for three of four residents (R7, R9, R15) reviewed for controlled medications in the sample list of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failure affects 4 of 6 residents (R1, R11, R12, R13) reviewed for infection control practices. 1.) The Centers for Disease Control and Prevention (CDC) Transmission Based Precautions dated 4/3/24 documents for contact precautions wear gown and gloves for all interactions that may involve contact with the patient or patient's environment, apply Personal Protective Equipment (PPE) upon room entry, and discard PPE before exiting the room. The facility's undated Respiratory Syncytial Virus (RSV) policy documents: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement pressure relieving interventions for one of five residents (R1) reviewed for wounds in the sample list of 15.

Inspectors wroteBased on interview and record review the facility failed to prevent falls by failing to identify trip hazards and implement fall interventions and failed to thoroughly investigate falls for two of three residents (R4, R14) reviewed for falls in the sample list of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from verbal abuse by a visitor. This failure affects one (R3) of four residents reviewed for abuse in the sample list of four.

Inspectors wroteFailures at this level required more than one deficient practice statementA. Based upon record review and interview, the facility failed to follow infection control policy and procedure during communicable disease outbreak. This failure had the potential to affect all 94 residents residing at facility. B. Based upon observation, interview and record review the facility failed to place a resident in contact isolation with Methicillin-Resistant Staphylococcus Aureus (MRSA) for one (R66) resident and operationalize its policy to wear proper PPE (personal protective equipment) during medication administration for one (R34) resident reviewed on contact isolation with Methicillin-Resistant Staphylococcus Aureus (MRSA) on a sample list of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain essential equipment to ensure a safe operating environment in a medication room. This failure has the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination of one (R66) resident's infected Diabetic Foot Ulcers out of two residents reviewed for skin conditions in a sample list of 41 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during urinary catheter care for one (R29) resident out of two residents reviewed for catheter care in a sample list of 41 residents.

Inspectors wroteBased on observation and interview the facility failed to properly maintain and store respiratory equipment. This failure has the potential to affect one of one residents (R3) reviewed for respiratory care on the sample list of 41. Findings Include: The facility's Tracheostomy Care policy dated [DATE] documents a replacement tracheostomy tube must always be available at the bedside. The same policy documents a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must always be available at the bedside. The same policy documents an emergency tracheostomy set up should be kept at the resident's bedside. R3's Medical Diagnoses dated [DATE] documents R3 is diagnosed with Anoxic Brain Damage, Anxiety Disorder, Paraplegia, Dependence on Supplemental Oxygen, and Tracheostomy Status. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate less than 5%. This error effects two (R33, R34) residents out of six residents reviewed for medication administration in a sample list of 41 residents. The facility medication error rate was 7.41% based on two medication errors out of 27 opportunities completed.

Inspectors wroteBased on observation, interview and record review the facility failed to properly dispose of medications for one (R61) resident out of six residents reviewed for medication administration in a sample list of 41 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise resident's care plans to accurately reflect resident's current status. This failure affects two residents (R1 and R3) out of the sample of three reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct safe transfers in accordance with a resident's care plan (R1), and failed to implement fall prevention interventions according to a resident's care plan (R2). These failures affect two residents (R1 and R2) out of the sample list of three reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were administered medications as prescribed per phyisican orders for (R1, R2, R3 & R4) of four residents reviewed for medication administration. This failure resulted in R1 being administered medications prescribed for another resident, to include a large dose of Morphine (Opiod Narcotic medication), resulting in R1 experiencing side effects for multiple days after and also requiring the administration of Narcan (Opiod Reversal Agent).

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during wound treatments for one of three residents (R3) reviewed for infected wounds on the sample list of three.

Inspectors wroteBased on observation, interview and record review the facility failed to complete physician ordered pressure ulcer treatments for one of three residents (R2) reviewed for infected wound/pressure ulcers on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep resident call buttons in an easily accessible area for four of five at risk residents (R2, R3, R4, R5) reviewed for call button accessibility on the sample list of five. Findings Include: 1. R2's Medical Diagnoses List dated January 2025 documents R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Dysphagia, Weakness, Dementia, and Difficulty Walking. R2's Care Plan dated May 2024 documents R2 is at risk for falls and staff should keep her call light within reach and encourage her to use it. R2 also has a communication problem related to Dementia and staff should make sure R2's call light is within reach and avoid isolation. R2 requires two person staff assistance for transfers and toileting. On 1/26/25 at 1:40 PM R2 was laying in her bed. She was the only person in her room. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of four (R1, R12, R13 and R14) of six residents reviewed for dignity from a total sample list of 15 residents.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough investigation for one (R1) of six residents reviewed for abuse from a total sample list of 15 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide nail care for one of six residents (R1) reviewed for activities of daily living from a total sample list of 15 residents.

Inspectors wroteBased on interview and record review the facility failed to provide a safe transfer of a resident (R1) when assisting the resident to transfer into bed. This failure resulted in R1 sustaining a right shoulder dislocation which required overnight hospitalization and a surgical intervention. R1 is one of four residents reviewed for accidents on the sample list of four. Findings Include: The facility Incident Report Investigation dated 10/9/24 documents on the morning of 10/9/24 R2 complained of pain in her right shoulder and was sent to the emergency room for evaluation. R2 stated she believed the injury occurred when a staff member (V4 Certified Nurses Assistant) CNA from the evening prior transferred her into bed. R2 was found to have a right shoulder dislocation that required surgical intervention. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident and mental abuse by a staff member. This failure affected three of four residents (R1, R3, R4) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Abuse means the willful infliction of injury, intimidation or punishment resulting in physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ the services of a full-time Director of Nursing. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the actual health status after a change in residents condition. This failure affects one resident (R1) out of three residents reviewed for care plans on the sample list of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician's ordered diagnostic test in a timely manner for one of two residents (R5) reviewed for Urinary Tract Infections on the sample list of 49. This failure extended R5's suffering for a total of six days with the following symptoms: painful and burning urination, abdominal pressure, and overall discomfort. Findings Include: R5's Medical Diagnoses list dated July 2024 documents R5 is diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 6/30/24 documents R5 complained of abdominal pain and burning and pain with urination. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain proper food storage order, failed to maintain dishwashing equipment to sanitize dish wares, and failed to maintain food contact equipment in a sanitary manner. These failures have the potential to affect all 99 residents residing in the facility. Findings Include: 1.) On 7/9/24 at 9:50 AM, in the facility's walk-in refrigerator, there was an opaque plastic tub with thawing raw pork sausage sitting on top of and in direct contact with thawing raw hamburger. On 7/9/24 at 9:50 AM, V3, Dietary Manager in Training, stated, Pork should be below hamburger. On 7/10/24 at 1:40 PM, V6, Dietary District Manager, stated, We follow the FDA (Food and Drug Administration) Code for food storage hierarchy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required members attended quarterly QAPI meetings. This failure has the potential to affect all 99 residents residing in the facility. Findings Include: The facility Long-Term Care Facility Application For Medicare and Medicaid dated 7/10/24 documents 99 residents residing in facility. The facility is unable to provide any documentation that the required quarterly QAPI meeting was held during the first quarter of 2024. The 2023 fourth quarter QAPI meeting sign in sheet, dated 2/23/24, does not document that an Infection Preventionist was present. On 7/10/24 at 2:40 PM V2 Director of Nursing said that they could not locate the minutes or sign in sheets for the 2024 first quarter QAPI meeting. [...]

Inspectors wroteBased on interview and record review the facility failed to establish a water management program including developing a risk assessment, ensuring that interventions to monitor control limits are met, and developing a method to audit the program to prevent the growth of Legionella and other water borne pathogens in the building's water systems. This failure has the potential to affect all 99 residents that reside in the facility. Findings Include: The facility Long-Term Care Facility Application for Medicare and Medicaid dated 7/10/24 documents that there are 99 residents who reside in the facility. The undated facility Water Management Program to Reduce Legionella Growth and Spread documents that each facility will complete a risk evaluation to identify if the entire building or parts of the building are at risk for Legionella growth and spread. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to place call light devices within resident's reach for four of four residents (R14, R27, R77, R95) reviewed for call lights in the sample list of 49. Findings Include: R14's undated Face Sheet documents R14's diagnoses as: Repeated Falls, Unsteadiness of feet, Muscle Weakness, and unspecified Dementia. R14's Care Plan dated 3/20/24, documents R14 as having a non-traditional call light. R14's Minimum Date Set (MDS) dated [DATE], documents R14 is dependent and requires substantial/maximal assist with moving in bed, rolling, lying, sitting, chair bed transfers, toilet transfers, dressing, and personal hygiene. R14's Brief Interview for Mental Status (BIMS) dated 7/1/24, documents R14 is not cognitively intact. On 07/09/24 at 10:03 AM R14's call light was on the floor near the bed and not within R14's reach. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly address multiple concerns of the resident council and facility grievances regarding laundry services. This failure effects 5 of 5 residents (R8, R15, R56, R78 and R81) who participated in Resident Council Meeting on the sample list of 49. Findings Include: Resident Council Meeting was held on 7/10/24 at 1:00 PM in the ADL (Activities of Daily Living) room. The Resident Council Members were R8, R15, R56 (Resident Council President), R78 and R81. During the meeting all five residents complained the facility did not return their personal items and clothing back in a timely matter. They also complained the clothes returned to them are not always clean and they appear as though they have not been washed. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a complete discharge summary for one of two residents (R101) reviewed for discharge on the sample list of 49. This past noncompliance occurred from 4/10/24-6/1/24. Findings Include: R101's Census Information dated 4/10/24 from the facility's EMR (Electronic Medical Record) documents R101 was admitted to the facility on [DATE] and was discharged on 4/10/24. R101's Medical Diagnosis sheet dated 2/14/24 in the EMR documents R101 is diagnosed with Metabolic Encephalopathy and Unspecified Convulsions. R101's Discharge summary dated [DATE] documents five separate sections with the following titles, Discharge Summary Recapitulation of Stay, Social Service Summary of Resident Stay, Clinical Summary of Resident Stay, Dietary Summary of Resident Stay and Activity Summary of Resident Stay. [...]

Inspectors wroteBased on interview and record review the facility failed to completed treatments as ordered for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample list of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and monitor a Peripherally Inserted Central Catheter (PICC) for one of two residents (R5) reviewed for Intravenous Catheter medication administration on the sample list of 49. Findings Include: R5's Medical Diagnoses list dated July 2024 documents R5 is diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 7/6/24 documents R5 stated she has had Urinary Tract Infection (UTI) symptoms and R5 requested to go to the emergency room. R5 was sent to the emergency room. R5's Health Status Note dated 7/8/24 documents R5 returned from the hospital after being admitted with a Urinary Tract Infection. [...]

Inspectors wroteBased on interview and record reviewed the facility failed to manage a resident's pain by failing to obtain pain medication and administer pain medication for one of one resident (R83) reviewed for pain management in the sample list of 49. Findings Include: R83's undated Face Sheet documents R83's diagnosis as: Bilateral Primary Osteoarthritis of Knee. R83's Physician Order Sheet (POS) dated July 2024 documents Oxycodone-Acetaminophen oral tablet 5-325 milligrams two tablets by mouth every four hours for pain management. R83's Medication Administration Record (MAR) documents on 7/9/24 at 12:00 PM a dose was not given and to see progress note. On 7/9/24 at 4:00 AM the MAR documents a dose not given and to see progress note and the same was documented on 7/9/24 at 8:00 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment for a newly developed skin wound for one (R1) of three residents reviewed for skin wounds in the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to remove an electric space heater from a resident's room for one of three residents (R1) reviewed for accidents in the sample list of three residents. This failure resulted in R1 burning R1's leg (fluid filled blister) when R1's leg came in contact with the space heater while R1 was getting out of bed. This past non compliance occurred on 5/29/24. The Current Physician Order Sheet (POS) documents the following diagnoses for R1: Central Cord Syndrome at Unspecified Level for Cervical Spinal Cord, Subsequent Encounter, Myasthenia Gravis without (Acute) Exacerbation and Chronic Obstructive Pulmonary Disease, Unspecified. The Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to protect resident's rights to be free from physical abuse by another resident. This failure affects five (R3, R4. R5, R6, R7) residents of 12 residents reviewed for abuse in a sample list of 12 residents.

Inspectors wroteBased on interview and record review the facility failed to protect residents from physical abuse from another resident with known physical aggression, failed to investigate resident allegations of abuse by another resident and allegation of potential abuse by staff. These failures affect five (R5, R6, R7, R3, R1) residents out of 12 residents reviewed for abuse in a sample list of 12 residents.

Inspectors wroteBased on interview and record review the facility failed ensure for resident rights regarding personal property for one (R1) of three residents reviewed from a sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to implement their abuse policy for one (R1) of twelve residents reviewed for abuse from a total sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to report allegations of physical and potential sexual abuse timely to the State Agency for three (R1, R6, and R7) of 12 residents reviewed for abuse from a total sample list of 12 residents.

Inspectors wroteBased on record review and interview the facility failed to protect a resident's right (R2) to be free from sexual abuse by another resident (R1). This failure affect two (R2, R1) of three reviewed for abuse on the sample list of 16. This past non-compliance occurred 03/03/24 (date of the incident) to 03/07/24 (facility plan completed to address non-compliance).

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer R1 to prevent a traumatic fall. This failure resulted in R1 falling face first into the ground causing a forehead laceration requiring 15 sutures at the hospital emergency department. R1 is one of three residents reviewed for accidents in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to prevent falls by failing to assist with ambulation and ensure a bed's wheel locks were in working order for two (R1, R2) of three residents reviewed for falls on the sample list of nine. These failures resulted in R1 sustaining a laceration to the forehead requiring emergency services and a subdural hemorrhage requiring hospitalization. These failures also resulted in R2 sustaining a left hip fracture which required surgical repair.

Inspectors wroteBased on interview and record review the facility failed to promote the right to respect and dignity during cares for one (R7) of three residents reviewed for improper nursing care on the sample list of nine.

Inspectors wroteBased on interview and record review the facility failed to provide physician ordered medications and notify the physician when medications were on backorder for one (R1) of three residents reviewed for resident injury on the sample list of nine.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment for two (R2, R8) of four residents reviewed for cleanliness from a total sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for changing a residents indwelling catheter every 30 days. This failure affects one (R6) of three residents reviewed for indwelling catheters from a total sample list of three. Findings Include: The facility (Indwelling) Catheter Insertion policy dated 01/2017 and (Indwelling) Catheter Removal Policy dated 01/2017 indicates that the nurse will verify the order for the procedure. R6's physician order sheet documents that on 10/29/23, V19 physician ordered an indwelling catheter change for R6 every 30 days and as needed. R6's progress note dated 10/29/23 indicates that R6's indwelling catheter was removed and a new indwelling catheter was inserted as directed by the physician. R6's medical record does not include another indwelling catheter change until 12/10/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food. This failure affects all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the hallway handrails were securely fastened to the walls. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the cleanliness of resident living quarters and bathrooms by failing to ensure residents had clean toilets to use and the disposing of soiled incontinence briefs in resident room garbage cans for five (R52, R61, R63, R69, R279) of five residents reviewed for dignity in a sample list of 43 residents.

Inspectors wroteBased on record review and interview the facility failed to offer and/or administer Pneumococcal Conjugate Vaccine (PCV) 20 or PCV 15 timely and failed to monitor vaccination status for four (R16, R20, R22, R34) residents out of five residents reviewed for immunizations in a sample list of 40 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's right to privacy during wound treatments administered by facility staff and agents. This failure affects one resident (R4) out of one reviewed for privacy on the sample list of 43.

Inspectors wroteBased on record review and interview the facility failed to complete, encode, and transmit a Minimum Data Set Assessment within the required timeframes. This failure affects two residents (R9 and R278) out of two reviewed for Minimum Data Set completion on the sample list of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement post-fall prevention interventions as documented on a resident's plan of care. This failure affects one resident (R27) out of five reviewed for accidents on the sample list of 43.

Inspectors wroteBased on observation, interview and record review the facility failed to properly date and store oxygen tubing and nebulizer tubing for three (R12, R31, R128) residents out of four residents reviewed for respiratory care in a sample list of 43 residents.

Inspectors wroteBased on record review and interview the facility failed to obtain a physician response from a pharmacist recommendation for a medication irregularity. This failure affects one resident (R33) out of five reviewed for unnecessary medications on the sample list of 43.

Inspectors wroteBased on observation, interview and record review the facility failed to properly store medications for three (R16, R20, R34) residents out of three residents reviewed for medication storage in a sample list of 43 residents.