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F0550
E

Failure to Maintain Resident Dignity During Care and Mealtime

Mattoon, Illinois Survey Completed on 09-05-2025

Penalty

3 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide dignity during incontinence care and mealtime for five residents, all of whom had significant cognitive or physical impairments. During incontinence care for one resident who was fully dependent and severely cognitively impaired, two CNAs exposed the resident's perineal area by pulling up her sweatshirt and pulling down her pants without ensuring privacy, as the privacy curtain was pushed back to the wall. This care was provided in the presence of the resident's roommate, who was also in the room at the time. One CNA acknowledged that the privacy curtain should have been pulled and that the resident was unable to provide privacy for herself. During a mealtime observation, four residents who were totally dependent on staff for eating and one resident who required supervision were seated together at a dining table with their food uncovered. No staff were present in the dining room while the residents were eating. When a CNA did assist, she did so by walking back and forth between residents, offering each a bite from a standing position rather than sitting with them individually. The CNA explained that staffing shortages due to call-ins left only two CNAs available for the front two halls, and the DON confirmed that ancillary staff are expected to help during such shortages. Facility policy requires that residents be treated with dignity and respect at all times.

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