Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Mattoon Rehab & Hcc during CMS and state inspections, most recent first.
A resident with diabetes, CKD, cirrhosis, and other complex conditions received insulin by syringe while also using an active insulin pump after an LPN misinterpreted the physician’s order. The resident later developed hypoglycemia, lethargy, and altered mental status, and was hospitalized for observation with suspected hepatic encephalopathy and concern for excess insulin administration.
Shower rooms on two halls were found with missing floor tile, damaged wall surfaces, debris, visible dirt, and black substance in the corners and along wall-to-floor junctions. In one shower room, shower chairs, a shower bed, and a mechanical lift blocked access to the toilet. The ADM stated the rooms had needed repair for some time and there were no work orders in place.
The facility failed to protect residents from verbal abuse and disrespectful treatment by staff. A resident with moderate cognitive impairment who required extensive assistance with toileting reported that a night-shift CNA repeatedly spoke to her in a rude, condescending manner and told her to manage toileting and transfers on her own, causing emotional distress and reluctance to request help. Two cognitively intact residents also reported that some staff spoke to them rudely or condescendingly, and one described being left in a soiled brief after staff said they would return but did not. These incidents show that multiple residents experienced or perceived verbally abusive or disrespectful interactions from staff, contrary to facility policy.
A resident with multiple lymphedema-related leg wounds did not receive wound care as ordered by an outside wound clinic, with treatment orders not properly transcribed to the TAR, no documented wound assessments for several weeks, and multiple days where wound treatments were not signed as given. A PTA performed dressing changes without documenting wound characteristics, reported deterioration with green drainage and odor, and did not use a gown or perform hand hygiene with each glove change despite open wounds and facility policies requiring Enhanced Barrier Precautions and specific hand hygiene practices. The resident was later found to have worsening wounds with purulent drainage and drug-resistant infection requiring hospitalization. In a separate case, another resident with severe cognitive impairment who self-propelled in a wheelchair sustained repeated skin tears to the same leg area, and the facility did not develop or document any interventions to prevent further skin tears after these incidents.
The facility failed to follow its own controlled substance policies for multiple residents, including not ensuring that Diazepam administrations were supported by an active order and documented on the MAR, and leaving controlled medications in the cart after a resident’s discharge. An LPN reported giving Diazepam out of habit without checking the MAR, while the DON confirmed that a pharmacy order had not been entered into the electronic record. Additionally, controlled medications such as Lorazepam, Norco, Morphine Sulfate, Lorazepam concentrate, and Fentanyl patches were documented as destroyed by an LPN, but the required second signature from a witnessing licensed professional was missing from the destruction forms, despite statements that the destruction had been jointly performed.
The facility failed to follow CDC guidance and its own policies for infection prevention and control. Two residents with RSV and coronavirus were placed only on droplet precautions, with missing contact precautions, incomplete PPE supplies, and staff entering their rooms wearing only masks or masks and gloves while providing direct care, handling items, and not discarding masks upon exit. A resident who developed multiple pressure ulcers, including a debrided stage 4 ulcer, was not placed on Enhanced Barrier Precautions (EBP), and staff reported that no gowns were used during care. Another resident with a stage 4 pressure ulcer, PICC line, and indwelling catheter had an EBP order and signage, yet two LPNs performed wound care wearing only gloves, without gowns, and one LPN did not perform hand hygiene between dirty and clean steps, changing gloves but not using hand sanitizer or washing hands.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and dependence for mobility developed multiple facility-acquired pressure ulcers, including a stage 4 ankle ulcer and unstageable heel, sacral, trochanter, and shin injuries. The care plan documented impaired skin integrity and use of pressure-reducing boots and mattress but did not include turning/repositioning needs or frequency. Pressure-relieving boots were discontinued during a hospital transfer and not resumed on return, and the resident remained on a flip foam pressure-reducing mattress that manufacturer information indicated was suitable only up to stage 2 ulcers, rather than an alternating pressure air mattress for stage 3–4 wounds. Staff interviews confirmed that repositioning and heel-floating standards were not clearly care-planned and that appropriate pressure-relieving interventions, including resumption of boots and use of an air mattress, were not implemented in accordance with facility policy and the resident’s condition.
Two residents with severe cognitive impairment and identified fall risks experienced multiple falls related to environmental hazards and incomplete fall investigations. One resident fell in the bathroom while attempting to toilet, with worn nonskid grip strips noted and no documentation of the last toileting, and later fell again after a room change when previously care-planned “call don’t fall” signs and grip strips were not documented as being in place. Another resident fell beside the bed after an attempted self-transfer and later fell from a wheelchair in the hallway, with investigations not clearly documenting the presence or condition of nonskid mats, and also sustained a skin tear when a CNA’s foot caught on a floor mat during a transfer. The DON confirmed that these investigations lacked key details such as toileting times and whether required environmental interventions were in place.
A resident with severe cognitive impairment and communication deficits was verbally abused by a visitor, who was witnessed by staff loudly shouting insults and profanities at the resident. The facility's policy requires immediate removal of such individuals and timely notification of law enforcement, but the report does not indicate these actions were taken at the time of the incident. The abuse was confirmed by multiple staff and documented in the resident's medical record.
The facility failed to follow infection control procedures during a respiratory outbreak affecting multiple residents, with no local health department notification and no formal outbreak review identified by leadership. The facility also failed to properly implement contact isolation and PPE use for a resident with MRSA and an infected foot wound; staff observed the room without isolation signage or readily available PPE, and an LPN completed wound care without gown and gloves. The resident’s care plan did not include isolation precautions, and the POA reported staff had been changing dressings without PPE.
A medication room sink had no hot or cold running water when an LPN attempted to wash her hands after disposing of a resident’s medication. The Maintenance Director also found no water flow and noted leaking pipes under the sink. In the same room, electrical cords from the medication management machine were stretched across the counter and touching the faucet near the sink, and the Administrator stated cords should not be near a water source.
Cross Contamination During Wound Care: An LPN performed dressing changes for a resident with infected diabetic foot ulcers using an uncleaned bedside table as the work surface, placing paper towels, ointment, calcium alginate, and scissors directly on the contaminated surface. The same scissors were used to cut the dressing material, and the LPN confirmed the supplies were not placed on a clean field and the table was not disinfected before use. Another LPN stated the resident’s foot ulcer had been cultured and the resident had been started on an antibiotic for a wound infection.
Cross contamination occurred during urinary catheter care for a cognitively intact resident who was dependent on staff for toileting, dressing, and personal hygiene. A CNA washed the resident’s perineal areas with soapy water but did not rinse off the soap, did not change gloves or perform hand hygiene before applying a new brief, did not keep the catheter secure while positioning the resident, did not wipe the catheter, and did not apply barrier cream. The facility’s catheter care policy required standard precautions and clean technique during catheter care.
Improper Storage and Maintenance of Tracheostomy Supplies: A resident with tracheostomy status and dependence on supplemental O2 did not have replacement trach tubes at the bedside as ordered. The emergency BVM was stored in a ripped belongings bag, supplies were expired, and an irrigation tray and sterile water container were not properly dated or maintained.
Medication error rate exceeded 5% after an LPN gave one resident’s scheduled Buspar 10 mg to the roommate instead of the intended resident. The two residents shared a room and had similar last names, and staff identified them by bed position on the door nameplates. The error was later documented in the nurse progress note and confirmed by the ADON/IP.
Improper Disposal of Dropped Medication: An LPN dropped a resident's Loratadine 10 mg during med prep, picked it up with a bare hand, and discarded it in the open garbage can attached to the med cart before replacing and administering the dose. The LPN stated she should have used gloves and not disposed of the medication in the open garbage can; the RCN stated meds should never be discarded that way and that the facility has a chemical agent for destroying medications.
The facility did not update care plans for two residents to reflect their current needs. One resident's care plan included interventions for personal items and a mirror that were no longer present or used, as confirmed by staff and observation. Another resident's care plan included staff education for denture assistance, despite the resident having natural teeth and no dentures, as documented in assessments and confirmed by staff and the resident.
Two residents at high risk for falls did not receive care in accordance with their care plans. One resident was transferred by a CNA alone, despite a requirement for two staff during transfers, and another resident did not have a required fall prevention sign in their room. These failures were confirmed through staff interviews, observation, and record review.
Several residents were affected by significant medication errors, including one who was given another resident's medications—among them a high dose of morphine—by an agency LPN unfamiliar with the facility's identification protocols. Other errors included a resident receiving an excessive dose of Trazodone due to overlapping orders and another receiving both Novolog and Aspart insulin because of incorrect order documentation. These incidents were linked to failures in resident identification and medication order management.
A resident with infected wounds did not receive proper wound care due to cross-contamination. An LPN used contaminated scissors to cut new wound dressings without cleaning them between uses, despite the facility's policy requiring clean or sterile scissors. The resident had recently completed IV antibiotics for a wound infection.
A facility failed to complete physician-ordered pressure ulcer treatments for a resident with severe pressure ulcers and other medical conditions. The resident's dressings were not changed as required, with documentation missing for a specific date. The Wound LPN confirmed the oversight, and the DON acknowledged issues with agency nurses not completing treatments, leading to a deficiency in care.
The facility failed to ensure call button accessibility for four residents with significant medical conditions, such as dementia and chronic obstructive pulmonary disease. These residents were found without accessible call buttons, contrary to their care plans, which increased their risk for accidents. The ADON confirmed the importance of having call buttons within reach, especially for high-risk residents.
Several residents in the facility experienced a lack of dignity and respect. A resident's request to change CNAs was ignored, another's privacy was breached by a visitor, and two residents felt disrespected by CNAs' behavior. These incidents highlight the facility's failure to honor residents' dignity and self-determination.
A resident sustained a fractured finger while being dressed by a CNA, but the facility failed to conduct a thorough investigation as per its abuse policy. The CNA was not interviewed or suspended, and the Director of Nursing admitted to not investigating the incident properly.
A resident with left side hemiplegia and cognitive intactness suffered a finger fracture due to inadequate nail care, as their long, untrimmed nails snagged on clothing. Despite a care plan to keep nails trimmed, observations showed nails nearly an inch long with debris underneath. The resident expressed a desire for nail clipping, indicating the facility's failure to follow the care plan.
A resident with a history of muscle weakness and previous shoulder dislocation was injured during a transfer when a CNA failed to follow the care plan requiring two staff members and the use of a gait belt. The resident's shoulder was dislocated, necessitating hospitalization and surgery.
A facility failed to protect residents from verbal and mental abuse, affecting three residents. A CNA threatened a cognitively intact resident with physical harm for using the call light. Additionally, two residents with depression engaged in a verbal altercation, exchanging curses and expletives, witnessed by the Social Services Director. The facility confirmed these behaviors as unacceptable.
The facility failed to employ a full-time DON, affecting all 90 residents. On a survey date, no DON was present to complete entrance paperwork. A Regional Nurse, not full-time, assisted in the absence of a DON. The previous DON's last working day was July 31, 2024.
A resident with a primary diagnosis of alcohol abuse returned to the facility intoxicated and belligerent on two occasions, yet the care plan was not updated to include interventions for alcohol abuse. Despite a care plan meeting and staff awareness of the issue, the care plan lacked necessary updates, leading to a deficiency.
A resident with a history of Bipolar Disorder, Depression, and Neuromuscular Dysfunction of the Bladder experienced a delay in receiving a physician-ordered urinalysis and culture for a suspected UTI. Despite reporting symptoms, the facility took three days to send the urine sample to the lab, resulting in a six-day delay in treatment. The resident's condition worsened, leading to hospitalization and treatment with intravenous antibiotics.
The facility failed to maintain proper food storage, dishwashing equipment, and cleanliness of food contact equipment, potentially affecting all 99 residents. Raw pork was improperly stored above raw hamburger, and the dishwasher was not sanitizing effectively due to low chlorine levels. The mixer was also found with dried food residues, indicating improper cleaning.
The facility did not hold the required quarterly QAPI meetings for the first quarter of 2024 and failed to ensure the presence of an Infection Preventionist at the fourth quarter 2023 meeting. The Director of Nursing confirmed the absence of documentation for the first quarter meeting and the missing Infection Preventionist in the previous meeting, contrary to the facility's policy requiring specific attendees.
The facility did not establish a water management program to prevent Legionella growth, lacking a risk evaluation, testing protocols, and intervention plans. The Clinical Director of Operations acknowledged the absence of these elements, citing the lack of a Maintenance Director. This deficiency potentially impacts all 99 residents.
The facility failed to ensure call lights were within reach for four residents, compromising their right to dignity and respect. Residents with various medical conditions, including dementia, fractures, and cognitive deficits, were found with call lights out of reach. An LPN confirmed that call lights should always be accessible, indicating a lapse in protocol adherence.
The facility failed to address resident concerns about laundry services, as noted in multiple Resident Council Meetings and the facility's Grievance Log. Residents reported delays and issues with the cleanliness of returned clothing. Observations showed a backlog of personal items in the laundry room, with staff indicating insufficient time to manage laundry duties effectively. The facility lacked a formal laundry policy.
A resident with Metabolic Encephalopathy and Unspecified Convulsions was discharged without a complete discharge summary. Only two out of five sections of the discharge summary were filled, contrary to the facility's policy requiring a full recapitulation of the resident's stay. The Director of Nurses confirmed the summary was incomplete, indicating a lapse in the discharge process.
A resident's pressure ulcer treatment was inaccurately administered by an LPN, who applied collagen to both the wound bed and peri-wound area, contrary to physician orders and manufacturer's instructions. The DON noted that the LPN should have measured the wound bed to apply collagen correctly.
A resident with a PICC line returned from the hospital with orders for intravenous antibiotics, but the facility failed to routinely monitor the PICC line. The resident, who is cognitively intact, reported that nursing staff only assessed the line during antibiotic administration. The DON confirmed that intravenous sites should be monitored and flushed every shift, with documentation of the site status.
A resident with Bilateral Primary Osteoarthritis of the Knee did not receive prescribed Oxycodone-Acetaminophen due to unavailability. The LPN discovered the shortage and contacted the doctor, but three doses were missed as the night shift failed to reorder or use the stat safe box. The DON noted that medication cards should prompt reordering before running out.
A resident with mobility issues developed a skin wound that was documented but not treated for four days. The LPN failed to notify the wound nurse and medical doctor promptly, contrary to the facility's policy on pressure ulcer prevention.
A resident sustained a burn injury from an electric space heater in their room, which was not removed by the facility. The resident, who requires assistance with daily activities, had purchased the heater and believed staff were aware of it. The heater was left on the floor, leading to the burn incident. The facility administrator admitted staff were unaware of the prohibition on electric heaters, highlighting a lapse in safety policy enforcement.
The facility failed to protect residents from physical abuse by another resident, R3, who exhibited aggressive behaviors. R3 physically assaulted other residents, including R7, R5, and R6, while being wheeled down the hallway by an LPN. Additionally, R4 was involved in a physical altercation with R3 in the dining room. The facility's staff failed to intervene appropriately, and the facility's abuse prevention policies were not adequately followed.
The facility failed to protect residents from physical abuse by another resident with known aggression and did not investigate abuse allegations by both residents and staff. An LPN wheeled an aggressive resident past others, resulting in physical altercations. Additionally, a resident reported feeling unsafe due to inappropriate behavior by a male CNA, but the facility did not investigate. These failures affected five residents out of a sample of twelve.
A CNA was observed going through a resident's drawers without permission, causing discomfort to the resident. The facility's Director of Nursing confirmed the grievance, and both the Assistant Director of Nursing and the Regional Clinical Director of Operations agreed that staff should always ask for permission before accessing a resident's personal belongings.
The facility failed to follow its abuse policy when a resident reported feeling unsafe due to a CNA. The Administrator did not investigate or report the allegation, and the CNA continued to work until later suspended. The Regional Clinical Nurse and Regional Director of Operations confirmed the policy was not followed.
The facility failed to report allegations of physical and potential sexual abuse involving a male CNA and a resident, as well as multiple resident-to-resident altercations. The incidents were not reported to the State Agency within the required timeframe, and there was a lack of documentation and investigation.
Failure to Follow Insulin Orders Resulted in Hypoglycemia and Hospitalization
Penalty
Summary
The facility failed to follow physician orders for insulin administration for one resident who had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, long-term use of insulin, chronic kidney disease, acute kidney failure, cirrhosis of the liver, and other significant medical conditions. The resident’s physician order directed insulin aspart 140 units subcutaneously one time a day for diabetes mellitus II via an insulin pump, with the pump changed every three days. On 4/2/2026, the medication administration record showed the insulin aspart order was marked administered at 8:00 AM, but no documentation was available showing the dose that was given. Blood sugar results on 4/2/2026 showed a reading of 169 mg/dL at 7:31 AM, then 50 mg/dL at 11:35 AM, followed by 78 mg/dL at 11:36 AM and 81 mg/dL at 4:06 PM. The record also documented glucose gel administration at 11:35 AM. The emergency department report stated the resident was admitted to the hospital medical floor on 4/3/2026 for observation with acute altered mental status and suspected hepatic encephalopathy, and that the resident had been less responsive since the prior morning with concern for possible excess insulin administration in the setting of an insulin pump. Interview statements identified that the resident was wearing an active insulin pump when an LPN administered insulin by syringe, and the LPN later stated she had misinterpreted the physician’s order. A family member reported the resident became lethargic and confused after the insulin was given, and another staff member stated the insulin pump alarmed for low blood glucose and the resident appeared very lethargic. The medical director stated the incorrect dose of insulin contributed to the resident’s hospitalization.
Shower Rooms Not Maintained in Clean, Safe Condition
Penalty
Summary
The facility failed to maintain resident shower rooms in a safe, clean manner and in good repair in two of three shower rooms on Beacon Hall and West Hall. Observations showed Beacon Hall Shower Room had missing floor tile with uneven and damaged areas, missing wallboard exposing underlying material, debris on the floor, visible dirt, and a black substance along the shower walls and floor corners. West Hall Shower Room had multiple missing tiles on the shower floor, shower chairs, a shower bed, and a mechanical lift blocking access to the toilet, dirt and debris on the floor, and a black substance along the wall-to-floor junctions and shower corners. The Administrator stated the shower rooms were in need of repair and had been that way for some time, and later stated there were no work orders in place to have the rooms repaired. A resident stated the shower room needed lots of work, especially under the sink where there was no wall. The midnight census report showed residents on Beacon Hall and West Hall used these shower rooms.
Failure to Protect Residents From Verbal Abuse and Disrespectful Staff Interactions
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse by staff, as required by its Abuse, Prevention and Prohibition Policy. One resident with moderate cognitive impairment, who required substantial/maximal assistance with toileting hygiene per the MDS, reported that a night shift CNA consistently told her to pull up her own incontinence brief and to perform toileting and transfer tasks independently. She described the CNA’s tone as mean, rude, and disrespectful, causing her emotional distress and making her hesitant to call for assistance when that CNA was working. Other CNAs corroborated that this resident had reported ongoing rude and condescending interactions from the identified night shift CNA, including being told she could do things herself in a demeaning manner. Two cognitively intact residents also reported staff speaking to them in a rude, condescending, or disrespectful manner. One resident stated that some staff had spoken to him in a condescending way and described an incident during a night shift when staff left him in a soiled incontinence brief after saying they would return, but they did not come back to provide care. Another resident reported that some nurses and CNAs had spoken to him rudely and disrespectfully and that he had brought these concerns to management. These reports, obtained through resident interviews and supported by staff interviews and documentation, demonstrate that multiple residents experienced or perceived verbal mistreatment and disrespectful communication from staff, contrary to the facility’s policy prohibiting verbal and mental abuse.
Failure to Provide Ordered Wound Care, Infection Control, and Skin Tear Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and skin management according to physician orders, facility policies, and resident needs for two residents. For one resident with multiple lower extremity lymphedema wounds, the facility did not ensure that wound care orders from an outside wound clinic were accurately transcribed and clarified, and the resident’s leg wound treatment orders were not placed on the Treatment Administration Records for November and December. The wound clinic ordered daily wound care, while the physician orders in the facility reflected wound care three times weekly tied to lymphedema treatments, with no documentation that this discrepancy was clarified. After a wound/skin assessment documented multiple leg wounds and their measurements in mid-December, there were no further documented wound assessments in the medical record until the resident was seen again at the wound clinic in early January, except for one refusal with no documented follow-up attempts. During this period, a Physical Therapy Assistant (PTA) performed lymphedema treatments and wound dressing changes three times weekly, but the PTA’s notes did not document wound characteristics or specific treatments. The PTA reported that the resident’s wounds deteriorated, with increased drainage and odor, and lymphedema therapy was stopped when the wounds began draining copious green fluid. Nursing notes documented a significant decline in the leg wounds with purulent green drainage and foul odor, and a wound culture was ordered along with oral antibiotics; however, the culture could not initially be obtained due to lack of culture kits. Later, a wound culture showed drug-resistant organisms. An infectious disease consultation documented that the resident’s wound dressings had not been changed for an extended period, with purulent drainage weeping through the dressings and foul odor, and that the resident required hospitalization for worsening chronic leg wounds and concern for infection. Hospital discharge instructions listed cellulitis of both legs, complicated wound infection, polymicrobial bacterial infection, and MDR Acinetobacter baumannii infection. The January Treatment Administration Record also showed multiple days when leg wound treatments were not signed as administered, and the resident reported that leg dressings were supposed to be changed daily but were sometimes forgotten. The facility also failed to implement appropriate infection control practices during wound care for this resident. The PTA reported that the resident was not on Transmission-Based Precautions or Enhanced Barrier Precautions and that a gown was not worn during wound treatments, despite the resident having open wounds. The PTA described performing hand hygiene before and after treatment but not routinely during glove changes, stating that hand hygiene during the procedure was only done if hands were visibly soiled, which did not align with the facility’s hand hygiene policy requiring hand hygiene with each glove change. The DON later confirmed that Enhanced Barrier Precautions should be implemented for open wounds and that a gown should be worn during wound care, and that hand hygiene should be performed with each glove change. For a second resident with severe cognitive impairment, the facility failed to develop and implement interventions to prevent recurrent skin tears. Incident reports documented that this resident, who self-propelled in a wheelchair, sustained a skin tear to the left lower leg and shin after hitting the leg on the bed, and then a subsequent skin tear to the left knee after bumping the knee while in the wheelchair. Despite these repeated skin tears, there was no documentation in the medical record of any interventions being developed or implemented to protect the resident’s skin from additional tears. The DON confirmed that there were no documented skin interventions following these incidents.
Failure to Properly Document and Destroy Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for, document, and destroy controlled medications in accordance with its own policies for multiple residents. The facility’s Controlled Substance Destruction Policy requires that controlled substances be destroyed by a licensed nurse and a licensed professional, with the destruction, quantity destroyed, and date documented on the controlled medication count sheet and signed by both individuals. The Controlled Substance Policy also requires nurses to sign out controlled medications on the Controlled Substance Proof of Use Form immediately and document administration on the MAR immediately after giving the dose. For one resident (R9), the Controlled Substance Record for Diazepam 2 mg showed single doses dispensed on four late-night occasions, all signed by an LPN, but these administrations were not recorded on the resident’s January and February MARs because there was no active order entered after 1/22/26. The resident’s census showed discharge on 2/14/26, and a subsequent check of the medication cart revealed remaining Diazepam tablets still present after discharge. The DON later confirmed that an active Diazepam order existed from the pharmacy but had not been entered into the electronic medical record and MAR, and the LPN acknowledged administering the medication “out of habit” without verifying it on the MAR. For another resident (R7), the Controlled Substance Record documented destruction of remaining Lorazepam and Norco tablets by an LPN on 2/9/26. The Narcotics Destruction Form for that date also listed destruction of multiple controlled medications for R7 and a third resident (R15), including Norco tablets, Morphine Sulfate solution, Lorazepam concentrate, and Fentanyl patches. However, these destruction forms contained only the LPN’s signature and lacked the required second signature of a witnessing licensed professional, contrary to the facility’s policy that controlled medications are destroyed with a floor nurse and either the DON or ADON, with two signatures documented. The DON and ADON both stated that they participated in the destruction but acknowledged that the ADON forgot to sign the destruction forms, leaving the documentation incomplete and not in compliance with the facility’s controlled substance procedures.
Failure to Implement Appropriate Precautions and Hand Hygiene for Residents With RSV and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate transmission-based precautions for residents with Respiratory Syncytial Virus (RSV) and coronavirus, and to follow CDC guidance and its own policies. Physician orders for two residents with RSV specified droplet precautions but did not include contact precautions, despite the facility’s RSV policy describing transmission via droplets and contaminated surfaces. Droplet isolation signs were posted on their doors, but one PPE container lacked gowns and there were no contact isolation signs. Staff, including CNAs and an OT, entered these rooms wearing only masks or masks and gloves, without gowns or eye protection, while providing direct care and assisting with mobility. One CNA delivered a meal tray, touched the overbed table, handled a used disposable cup, and exited the room without wearing gown, gloves, or eye protection and without discarding the mask upon exit. Staff interviews showed inconsistent understanding of required PPE, and the DON later stated that both droplet and contact precautions with full PPE should have been followed for RSV. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident who developed multiple pressure ulcers. This resident had a facility-acquired unstageable pressure ulcer on the left ankle that progressed and was later reclassified as a stage four pressure ulcer requiring debridement, and also developed an unstageable pressure ulcer on the left heel. Despite the presence and progression of these open wounds, there was no documentation in the medical record that EBP had been initiated, and the DON confirmed there was no EBP order. A CNA who cared for the resident on the day of transfer to the hospital stated the resident was not on any precautions and gowns were not worn during care, contrary to CDC guidance and the DON’s statement that EBP is implemented for open wounds. In addition, the facility did not ensure adherence to its hand hygiene policy and EBP requirements during wound care for another resident with a stage four pressure ulcer, a PICC line, and an indwelling urinary catheter. This resident had an EBP order and signage on the door instructing staff to wear gown and gloves for high-contact care activities, including wound care. Two LPNs entered the room wearing only gloves, without gowns, and one LPN performed wound cleansing and dressing changes without a gown and without performing hand hygiene between dirty and clean steps of the procedure, changing gloves but not using hand sanitizer or washing hands. The LPN later confirmed not wearing a gown and not performing hand hygiene, believing it was only necessary when hands were visibly soiled, despite the facility’s policy requiring hand hygiene even when gloves are used and the DON’s expectation for hand hygiene with each glove change during wound care.
Failure to Implement Appropriate Pressure-Relieving Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement appropriate pressure-relieving interventions and care planning for a resident at high risk for pressure ulcers who had multiple facility-acquired wounds. The facility’s policy required initiation of preventive and treatment interventions, updating the care plan with each intervention, use of pressure-reducing surfaces based on a mattress selection algorithm, and frequent repositioning for bed- or chair-bound residents. The resident’s care plan, revised in late January, documented impaired skin integrity related to recent surgery, impaired mobility, incontinence, diabetes, and multiple pressure ulcers, including a stage 4 left ankle ulcer and an unstageable left heel ulcer. However, the care plan did not include turning/repositioning needs or frequency, despite the resident’s high Braden risk score and dependence on staff for transfers and rolling in bed. Clinical documentation showed progressive worsening and development of multiple pressure ulcers over time. Initial skin/wound notes identified a facility-acquired unstageable left ankle pressure ulcer on 12/24, which later enlarged and was reclassified as a stage 4 pressure ulcer, and a new unstageable left heel ulcer identified in January. Additional facility-acquired unstageable/deep tissue injuries to the sacrum, left trochanter, and right shin were documented on 1/20. The wound NP’s note indicated differential diagnoses for the left ankle wound, including pressure injury, and directed continuation of pressure-relieving interventions such as a pressure-reducing mattress, routine repositioning, and offloading boots as tolerated. The resident also had significant comorbidities, including dementia, adult T-cell lymphoma/leukemia not in remission, chemotherapy-induced pancytopenia, and type 2 diabetes, and had experienced substantial recent weight loss with poor intake. Staff interviews and record review revealed failures to implement and maintain ordered pressure-relieving devices and to use an appropriate support surface consistent with facility policy and manufacturer guidance. Pressure-relieving boots were initiated when the left ankle ulcer was first identified but were discontinued when the resident was transferred to the emergency room and were not resumed upon return, as confirmed by the DON and TAR review. The LPN and wound nurse acknowledged that the resident did not have an air/alternating pressure mattress and was on a standard pressure-relieving (flip foam) mattress, which manufacturer information indicated was appropriate only up to stage 2 pressure wounds. The wound nurse stated that air mattresses are used for stage 3 or 4 ulcers but that this was not discussed with a provider because boots were in place, and later acknowledged not realizing the limitation of the standard mattress. Staff also reported that the resident required two-person assistance for repositioning, that the standard of care was to float heels and reposition at least every two hours, and that the care plan lacked repositioning instructions and pressure-relieving interventions for the feet prior to late December.
Failure to Maintain Safe Environment and Adequate Fall Prevention for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall interventions for cognitively impaired residents at risk for falls. The facility’s Skilled Fall Policy requires completion of an occurrence report after each fall to determine root cause and implement interventions. For one resident with severe cognitive impairment and a care plan identifying fall risk related to muscle weakness, dementia, impaired hearing and vision, impaired balance, and a history of falls, the care plan included interventions such as “call don’t fall” signage and nonskid grip strips in the bathroom, in front of the bathroom door, in front of the recliner, and on the bathroom floor. During a fall on 1/10/26, the resident was found on the floor in front of the toilet with pants down and incontinent of bowel movement after attempting to go to the bathroom, and the MDS Coordinator noted the grip strips in front of the toilet were worn down and replaced them. The fall investigation did not document when the resident was last toileted prior to the fall. A subsequent fall for the same resident on 1/19/26 occurred after a room change. The resident, who normally used the call light, was described as more confused that night and attempted to get up unassisted from a recliner and fell in front of the bathroom. Staff interviews and interdisciplinary notes indicated that the resident was more confused due to the recent room change and attempted to self-transfer. There was no documentation that the new room had the previously care-planned “call don’t fall” signs and nonskid grip strips in place at the time of the fall. The DON confirmed that grip strips and “call don’t fall” signs were current interventions that should have been moved with the resident during the room change and that the fall investigation did not document whether these interventions were in place when the resident fell. Another resident with severe cognitive impairment and requiring partial/moderate assistance for transfers experienced multiple falls where investigations lacked key information and environmental hazards were not fully addressed. A fall on 12/19/25 occurred when the resident was found sitting on the floor beside the bed, later documented as an attempted self-transfer from wheelchair to bed with incontinence at the time of the fall; the investigation did not identify the last time the resident was toileted, and a new intervention of nonskid grip strips next to the bed was added. A later fall on 2/3/26 involved the resident falling from a wheelchair in the hallway with the wheelchair tipped and a foot pedal under the resident; the investigation did not identify whether a nonskid mat was in the wheelchair, though the care plan was updated to replace the nonskid mat. Another incident on 2/19/26 occurred during a staff-assisted transfer when a CNA’s foot became caught on a floor mat, causing loss of balance and the resident being lowered to the floor, resulting in a skin tear; the DON later confirmed that the post-fall intervention was to pick up the floor mat when the resident was out of bed.
Failure to Protect Resident from Verbal Abuse by Visitor
Penalty
Summary
A resident with severe cognitive impairment, dementia, and impaired mobility was subjected to verbal abuse by a visitor. The facility's policy requires that residents be protected from abuse by anyone, including visitors, and specifies immediate removal of the alleged perpetrator from contact with residents pending investigation. On the day of the incident, a visitor was observed by staff and another resident's family member verbally abusing the resident, including yelling derogatory statements such as calling the resident a child, idiot, and using profane language. Multiple staff members, including an LPN and a CNA, witnessed the visitor in close proximity to the resident, loudly shouting insults and profanities. The resident, who has documented communication problems and requires staff assistance for activities of daily living, appeared confused and unsure of the situation during the incident. The facility's records confirm that the verbal altercation occurred and that the resident was the victim of verbal abuse by the visitor. The incident was reported to the state agency, and the facility's Director of Nursing and Regional Nurse Consultant both confirmed the occurrence of the abuse. The report does not detail any immediate removal of the visitor at the time of the incident, nor does it mention timely notification of law enforcement as outlined in the facility's policy.
Infection Control Failures During Outbreak and Isolation Care
Penalty
Summary
The facility failed to follow infection control policy and procedure during a communicable disease outbreak. The census showed 94 residents in the facility, and the Infection Surveillance Monthly Report for June 2025 documented 10 residents with respiratory infections, 5 with pneumonia, 5 with COVID-19, and 1 with bronchitis. These 21 residents had similar symptoms and were placed on droplet isolation precautions. The Assistant Director of Nursing/Infection Preventionist stated she did not notify the local health department regarding the upper respiratory infection outbreak, no emergency quality meeting was held to identify the source, trend, or plan of action, and the Regional Nurse stated no formal Prevention Identification Plan had been conducted regarding the respiratory outbreak. The facility also failed to place a resident with MRSA in contact isolation and did not operationalize its policy for proper PPE use during care. One resident’s MDS documented cognitive intactness and need for moderate assistance with toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. The resident was receiving antibiotic therapy for a wound infection, but the care plan did not include a focus area, goal, or intervention for isolation precautions. During multiple observations, the resident’s room door did not designate isolation precautions and PPE was not easily accessible; later, PPE was available from a container attached to the door. An LPN stated the resident did not require isolation precautions for the open, infected left lateral foot diabetic foot ulcer because the wound was smaller than a band-aid. Another LPN stated the wound had been cultured and the resident had been started on an antibiotic. A third LPN stated she completed the wound treatment without wearing proper PPE and said she was unaware the resident was on isolation precautions because there were no isolation signs on the room door. The resident’s POA stated staff had only just started wearing PPE and reported that staff had been changing the resident’s foot dressings without PPE.
Nonfunctional Medication Room Sink and Unsafe Cord Placement
Penalty
Summary
The facility failed to maintain essential equipment in the [NAME] hall nurses medication room when the sink did not have hot or cold running water. During observation, an LPN disposed of a resident’s medication in the medication room, applied soap to her hands, and turned on the sink handles, but no water flowed from either side. The LPN stated the nurses medication room should have a working sink for handwashing and said she did not have time to run from hall to hall to find a working sink. The facility daily census dated 9/14/25 documented 94 residents in the facility. The Maintenance Director later attempted to turn on both the hot and cold water and also found no water flow. He opened the cabinets under the sink and tried to fix the issue, then stated the pipes were leaking underneath the sink while he was attempting the repair. He said he was not aware the sink was not working and did not know who shut the water off. The Administrator stated each nurses station should have a functional sink with both hot and cold running water, and that the [NAME] hall sink would be fixed as soon as possible. Observation also showed electrical cords from the facility’s medication management machine stretched across the countertops, behind and touching the faucet, and plugged into a wall outlet on the opposite side of the sink. The Maintenance Director stated electrical cords should not be that close to a water source, and the Administrator stated the facility should not have electrical cords near a water source.
Cross Contamination During Wound Care
Penalty
Summary
The facility failed to prevent cross contamination during wound care for one resident with infected diabetic foot ulcers. The resident was cognitively intact per the MDS and required moderate assistance with toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. Physician orders in September 2025 directed daily cleansing of the left lateral diabetic foot ulcer with wound cleanser, Santyl, calcium alginate, and a dry dressing, and daily cleansing of the right second toe diabetic foot ulcer with wound cleanser, calcium alginate, and a dry dressing. During wound care, an LPN performed dressing changes for both ulcers and observed that the wounds were open and wet with drainage, with dressings not in place before the procedure. The LPN placed paper towels from the resident’s room onto an uncleaned bedside table, then placed the resident’s chemical debriding ointment, calcium alginate, and scissors directly on that contaminated surface. The same scissors were used to cut the calcium alginate to size, and the ointment and dressing material were then applied directly to the open wounds. Another LPN stated the resident’s left lateral foot ulcer had been cultured the prior week and the resident had been started on an antibiotic for a wound infection. The LPN later confirmed the wound supplies were not placed on a clean field and that the bedside table had not been disinfected before the supplies were placed on it. A clinical reimbursement specialist stated that she and the regional clinical nurse were unable to find a policy on clean dressing changes.
Cross Contamination During Catheter Care
Penalty
Summary
Failure to provide appropriate catheter care and prevent cross contamination occurred during urinary catheter care for one cognitively intact resident who required maximum staff assistance for personal hygiene and was dependent on staff for toileting and dressing. During catheter care, a CNA prepared a basin of soapy water but did not rinse the resident’s front or rear perineal areas after washing with soap. The resident was incontinent of bowel, and the CNA did not change gloves or perform hand hygiene after cleansing the perineal areas and before applying a new incontinence brief. The resident’s urinary catheter leg drainage bag was pulled taut during positioning, and the CNA did not ensure the catheter was held secure while providing perineal care. The CNA also did not wipe the urinary catheter during care and did not apply barrier cream afterward. The CNA stated she should have changed gloves after cleansing the perianal area and before applying the brief, and stated not rinsing off the soap could cause skin irritation. The Administrator stated staff should follow policy during all care and that cross contamination could put residents at a higher risk of infection. The facility’s urinary catheter care policy required standard precautions, clean technique, cleansing and rinsing the labia, and cleansing and rinsing the catheter from the insertion site outward.
Improper Storage and Maintenance of Tracheostomy Supplies
Penalty
Summary
The facility failed to properly maintain and store respiratory equipment for a resident with anoxic brain damage, anxiety disorder, paraplegia, dependence on supplemental oxygen, and tracheostomy status. The facility’s tracheostomy care policy required a replacement tracheostomy tube, suction machine, suction catheters, exam and sterile gloves, flush solution, and an emergency tracheostomy setup to always be available at the bedside. The resident’s physician orders also directed staff to maintain suction setup, an emergency bag valve mask, and replacement tracheostomy tubes of equal size and one size down at the bedside at all times. During observation, there were no tracheostomy tubes at the resident’s bedside. The emergency bag valve mask was stored in a ripped belongings bag with a date on it, and the lubricant and other supplies in the bag were expired. There was also an irrigation tray with an expiration date, and the container of sterile water was more than halfway gone and was not marked with the date it was opened. The administrator and director of clinical services confirmed that extra tracheostomy tubes needed to be kept at the bedside, opened containers of multiuse liquids needed to be dated, and emergency and tracheostomy supplies needed to be checked regularly for expiration and integrity.
Medication Error Rate Exceeded 5% Due to Wrong-Resident Buspirone Administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with a reported error rate of 7.41% based on two medication errors out of 27 opportunities. The deficiency involved two residents, R33 and R34, who share the same last name and share a room. R33 had a physician order to receive Buspirone HCl (Buspar) 10 mg daily, while R34’s physician order sheet did not document a Buspar order. The EMR identified R33 as residing in bed two and R34 as residing in bed one, and the residents’ nameplates outside the room identified them by bed position as “D” and “W.” On 9/15/25 at 12:40 PM, an LPN prepared R33’s Buspar 10 mg at the medication cart outside the room and administered it to the resident in the bed by the door, which was R34, instead of to R33. A nurse progress note later documented that R34 received the roommate’s scheduled Buspirone 10 mg. The ADON/IP confirmed that R33’s Buspar 10 mg was given to R34 in error, and staff stated that nurses should verify they are administering the correct medication to the correct resident. The facility policy stated that medications should be recorded immediately after ingestion and that physicians should be notified if an order cannot be followed or if a medication error occurs.
Improper Disposal of Dropped Medication
Penalty
Summary
The facility failed to properly dispose of medication for one resident, R61, who had a physician order in the September 2025 Physician Order Sheet for Loratadine 10 mg daily. On 9/16/25 at 8:00 AM, an LPN prepared R61's medications for administration and dropped the Loratadine 10 mg onto the top of the medication cart. The LPN then used her bare hand to pick up the dropped tablet and placed it into the garbage can attached to the medication cart, then replaced the Loratadine 10 mg for administration. The LPN administered R61's medications without washing her hands or performing hand hygiene after disposing of the dropped medication. Later that morning, the LPN stated she should have used gloves to pick up the dropped Loratadine and should not have disposed of it in the open garbage can. The RCN also stated nurses are supposed to use a glove when handling all medications and that medications should never be disposed of in an open garbage can; she noted the facility has a chemical agent kept in the nursing medication room for destroying medications. The facility policy stated residents' medications shall be properly labeled and stored in locked medication storage areas or locked mobile medication carts.
Failure to Update Care Plans to Reflect Residents' Current Status
Penalty
Summary
The facility failed to revise and update care plans to accurately reflect the current status of two residents reviewed for falls. For one resident, the care plan included interventions to ensure personal items, including a mirror, were within reach, but repeated observations showed that no personal items or mirror were present in the resident's room. Staff interviews confirmed that the resident no longer had or used these items, and had not done so for a significant period. For another resident, the care plan included an intervention to educate staff to assist with dentures, but both the resident and staff confirmed that the resident had natural teeth and did not have dentures. Nursing and nutritional assessments also documented that the resident had natural teeth and no dentures, indicating the care plan was not updated to reflect this change.
Failure to Follow Care Plans for Safe Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure safe transfers and implement fall prevention interventions as outlined in the care plans for two residents. One resident, identified as high risk for falls, had a care plan requiring two staff members for all transfers. Despite this, a Certified Nursing Assistant reported transferring the resident alone, having the resident wrap their arms around her neck and performing the transfer without assistance. This was confirmed through staff interview and review of the resident's care plan and progress notes, which documented a recent fall and the resident's unsteady condition during transfers. Another resident, also assessed as high risk for falls with a documented history of multiple falls, had a care plan intervention requiring a "call don't fall" sign to be placed in their room. Observation revealed that the sign was not present, and this was confirmed by a Licensed Practical Nurse. The absence of the required signage and failure to follow the care plan intervention were directly observed and verified through staff interview and record review.
Multiple Medication Administration Errors Due to Misidentification and Order Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of incorrect medications or dosages to several residents. One resident was administered another resident's scheduled medications, which included a large dose of extended-release morphine, after an agency LPN misidentified the resident. The error was discovered when the resident refused a medication not prescribed to him, but by that time, he had already ingested the other pills. The resident subsequently experienced prolonged side effects, including nausea, vomiting, lethargy, and refusal of meals, and required administration of Narcan to reverse the opioid effects. Another resident received an excessive dose of Trazodone due to a failure to discontinue a previous order when the dosage was increased, resulting in the resident receiving both the old and new dosages. The resident was informed of the error and reported no ill effects other than increased drowsiness. Additionally, a third resident was administered both Novolog and Aspart insulin due to an incorrectly documented order, rather than receiving only the prescribed Novolog with meals. The resident did not experience adverse effects, as her blood sugars had been running high. Interviews with staff revealed that proper resident identification protocols were not consistently followed, with reliance on visual identification and verbal confirmation that proved insufficient. The agency LPN involved in the morphine error was unfamiliar with the facility's bed numbering system, contributing to the misidentification. The DON and clinical director acknowledged the errors and the need for further staff education on using two resident identifiers and verifying medication orders to prevent such incidents.
Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to prevent cross-contamination during wound treatments for a resident with infected wounds. The resident, who had no cognitive impairment, was at risk for pressure ulcers and had two venous and arterial ulcers. The resident's treatment orders included specific wound care instructions and antibiotic medication for a multi-organism wound infection. During an observation, it was noted that the resident's compression stockings were soiled, and the wound dressing on the right lower leg had wet drainage. The LPN involved in the wound care did not adhere to proper infection control practices. After removing the soiled gauze wrap from the resident's right lower leg, the LPN used the same contaminated scissors to cut a new calcium alginate pad for the wound bed. The scissors were placed on the bedside table next to clean dressing supplies without being cleaned. This process was repeated for the resident's left lower leg wound, again using the contaminated scissors without cleaning them between uses. The Director of Nursing confirmed that the facility's policy required clean or sterile scissors to prevent cross-contamination during wound treatments. The LPN acknowledged the oversight, stating that the scissors should have been cleaned with an alcohol or bleach wipe after each use. The Wound Nurse also observed the failure to clean the scissors, noting that the resident had recently completed intravenous antibiotics for an infection in the right ankle wound.
Failure to Complete Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to complete physician-ordered pressure ulcer treatments for a resident with significant medical conditions, including the absence of both legs, peripheral vascular disease, and severe pressure ulcers. The resident's medical records indicated the presence of a Stage III pressure ulcer on the right trochanter and a Stage IV pressure ulcer on the coccyx, with specific treatment orders to be followed daily. However, the Treatment Administration Record showed no documentation of treatment completion on a specific date, indicating a lapse in care. During an observation, it was noted that the resident's pressure ulcer dressings were not changed as required, with the dressing dated two days prior and visibly saturated with drainage. The Wound LPN acknowledged the oversight, stating that the dressings should be changed daily and that the resident was on antibiotics for osteomyelitis related to the wounds. The resident confirmed that no nurse attended to the dressings the previous day, highlighting a failure in the facility's wound care protocol. The Director of Nursing provided the facility's policy on pressure injury assessment and treatment, which mandates that wound dressings be dated and initialed by the nurse completing the treatment. The DON acknowledged issues with agency nurses not completing treatments, which contributed to the deficiency. This lapse in care was observed and documented by surveyors, indicating a failure to adhere to established treatment guidelines and physician orders.
Failure to Ensure Call Button Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call buttons were accessible to residents, which is a critical aspect of resident safety and care. Four residents, all with significant medical conditions such as dementia, chronic obstructive pulmonary disease, and difficulty walking, were found without accessible call buttons. For instance, one resident with chronic obstructive pulmonary disease and dementia was found in bed with her call button out of reach, despite her care plan indicating the need for it to be within reach due to her fall risk and communication problems. Another resident, who was at risk for falls and had swallowing difficulties, was found in a family room without access to a call button and without supervision while eating, which is contrary to his care plan requirements. Additionally, a resident with congestive heart failure and vascular dementia was found in a recliner with no accessible call button, and she expressed difficulty in finding it. Another resident, diagnosed with dementia and a history of falls, was found asleep in bed with the call button on the floor, far from reach. The Assistant Director of Nurses confirmed that all residents should have call buttons within reach, especially those at higher risk for accidents. This deficiency highlights a systemic issue in ensuring resident safety and adherence to care plans regarding call button accessibility.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to honor the dignity and self-determination of several residents, as evidenced by multiple incidents. One resident, who was cognitively intact and dependent on staff for activities of daily living, expressed dissatisfaction with the care provided by a specific CNA. Despite the resident's complaint and the facility's documentation stating that the CNA would no longer provide care to this resident, the CNA continued to do so, disregarding the resident's wishes. Another resident experienced a breach of privacy and dignity when a roommate's boyfriend entered her room while she was undressed and did not leave immediately, causing her distress and embarrassment. Additional incidents involved residents feeling disrespected by staff. One resident reported that a CNA was unkind and dismissive of her requests, yet continued to provide care despite the resident's complaints. Another resident, who was dependent on staff for mobility and toileting, felt disrespected when two CNAs laughed while assisting her, making her feel uncomfortable and disrespected. These incidents highlight the facility's failure to ensure the dignity and respect of its residents, as well as a lack of adherence to residents' expressed preferences and needs.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident who sustained a fractured finger. The facility's abuse policy mandates a comprehensive investigation involving interviews with witnesses, staff, and residents, as well as the suspension of the alleged perpetrator pending the investigation's outcome. However, the investigation into the resident's injury was incomplete, as no interviews were conducted with the Certified Nursing Assistant (CNA) involved, nor with other staff or residents who might have had relevant information. Additionally, the CNA was not suspended during the investigation process. The incident involved a resident who was found with a bruised left hand, and an X-ray confirmed a fracture in the third finger. The injury reportedly occurred while the CNA was dressing the resident. Despite the facility's policy, the Director of Nursing admitted to not investigating the cause of the injury thoroughly, citing being off-site and preoccupied with other tasks. The lack of a comprehensive investigation and failure to suspend the CNA during the investigation process contributed to the deficiency identified by the surveyors.
Failure to Provide Adequate Nail Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for activities of daily living due to left side hemiplegia. The resident, who was cognitively intact, suffered a fracture on the left middle finger after a cracked fingernail snagged on clothing during dressing. This incident was documented in a facility report dated 11/26/24, following the discovery of a bruise and subsequent X-ray on 11/25/24. The resident's care plan, updated on 11/26/24, specified the need to keep nails trimmed to prevent snagging. However, observations on 12/12/24 and 12/16/24 revealed that the resident's nails were nearly an inch long with food and brown matter underneath, indicating a lack of proper nail care. The resident expressed a desire to have the nails clipped, highlighting the facility's failure to adhere to the care plan and prevent the injury.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a right shoulder dislocation that required hospitalization and surgical intervention. The incident occurred when a Certified Nurses Assistant (CNA) transferred the resident into bed without assistance from another staff member and without using a gait belt, despite the resident's care plan indicating the need for two staff members for transfers. The resident, who has a history of muscle weakness, unsteadiness, repeated falls, reduced mobility, and a previous shoulder dislocation, reported that the CNA pulled on her arm or moved it incorrectly during the transfer, leading to the injury. The CNA admitted to transferring the resident alone and without a gait belt, and was unsure if the resident was supposed to be wearing a sling, which was required at all times according to the physical therapist. The resident experienced extreme pain following the transfer, which was not addressed until the following morning when a nurse assessed the situation and sent the resident to the emergency room. The facility's failure to adhere to the resident's care plan and ensure proper transfer procedures directly contributed to the resident's injury.
Verbal and Mental Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse, affecting three out of four residents reviewed for abuse. One incident involved a Certified Nurses Assistant (CNA) making inappropriate and threatening statements to a resident, who was cognitively intact and had medical diagnoses including cerebral infarction and muscle weakness. The resident reported that the CNA threatened to beat him if he continued to use his call light, which was confirmed by the facility's administrator as unacceptable behavior. Another incident involved a verbal altercation between two residents, both diagnosed with depression, where one resident blocked the dining room entrance and refused to move, leading to an exchange of curses and expletives. The altercation was witnessed by the Social Services Director, who confirmed that the behavior was inappropriate and not condoned by the facility. The resident involved in the altercation had a history of verbal altercations with other residents, as documented in their care plan.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ the services of a full-time Director of Nursing (DON), which has the potential to affect all 90 residents residing in the facility. On August 14, 2024, at 9:05 AM, there was no DON present in the building to complete entrance paperwork. At 9:10 AM, a Registered Nurse/Minimum Data Set/Care Plan Coordinator confirmed that the facility does not have a full-time DON. At 9:25 AM, a Regional Nurse, who is not full-time at the facility and works there on average two days a week, completed the entrance paperwork. This Regional Nurse was helping the facility in the absence of a full-time DON. On August 15, 2024, at 11:45 AM, the previous DON stated that her last day working in the facility was July 31, 2024. The facility's 802 Matrix dated August 14, 2024, documented that 90 residents are currently residing in the facility.
Failure to Update Care Plan for Alcohol Abuse
Penalty
Summary
The facility failed to revise a resident's care plan to reflect the actual health status after a change in the resident's condition. The resident, who had a primary diagnosis of uncomplicated alcohol abuse, returned from being out in the community with the smell of alcohol and exhibited belligerent behavior. Despite this change in condition, the resident's care plan did not include interventions related to alcohol abuse or strategies to prevent future exacerbations. This oversight was noted during a review of the resident's care plan, which was last updated without addressing the primary diagnosis or the recent incidents of alcohol intoxication. The resident experienced two significant events related to alcohol intoxication, both of which were documented in the facility's records. The first incident involved the resident returning to the facility intoxicated, leading to a hospital evaluation. A care plan meeting was held afterward, but the care plan was not updated to include interventions for alcohol abuse. The second incident occurred two weeks later, with the resident again exhibiting signs of intoxication and belligerence, resulting in a 72-hour psychiatric hold. Despite these events, the care plan remained unchanged, lacking any mention of alcohol-related interventions. Interviews with facility staff revealed a lack of communication and coordination in updating the resident's care plan. The Social Service Director and the Care Plan Coordinator were unaware of the need to update the care plan to address the resident's alcohol issues. The Regional Nurse confirmed that alcohol abuse should have been included in the care plan. The facility's policy on care planning emphasizes the importance of addressing all relevant care issues, yet this was not adhered to in the resident's case, leading to the deficiency.
Delayed Diagnostic Testing for UTI
Penalty
Summary
The facility failed to obtain a physician-ordered diagnostic test in a timely manner for a resident diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of the Bladder, who was cognitively intact. The resident began experiencing symptoms of a urinary tract infection (UTI), including painful and burning urination, abdominal pressure, and overall discomfort. Despite notifying the medical director and receiving an order for a urinalysis and culture and sensitivity test, the facility delayed sending the urine sample to the lab for three days. Consequently, the resident's symptoms persisted without treatment for six days. The medical director confirmed that the urinalysis should have been sent to the lab on the day it was ordered. Due to the delay, the resident's condition worsened, leading to a request to go to the emergency room, where the resident was diagnosed with a UTI and treated with intravenous antibiotics. The resident expressed frustration over the delay in treatment, stating that she knew her body and needed to be treated sooner. The medical director acknowledged that if the urine had been sent to the lab sooner, treatment could have been initiated earlier.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage, dishwashing equipment, and cleanliness of food contact equipment, potentially affecting all 99 residents. During an inspection, it was observed that raw pork sausage was improperly stored on top of raw hamburger in the walk-in refrigerator, contrary to the FDA Code and facility policy, which require separation to prevent cross-contamination. The Dietary Manager in Training acknowledged the error, and the Dietary District Manager confirmed adherence to the FDA Code for food storage hierarchy. Additionally, the facility's dishwasher was not sanitizing dishware effectively due to insufficient chlorine levels. A test conducted by the Dietary Manager in Training showed less than 10 ppm of chlorine, below the recommended 50-100 ppm. The dishwasher log was found to be illegible and altered, with discrepancies in recorded chlorine levels. Furthermore, the mixer in the kitchen was found with dried food residues, indicating it was not cleaned properly. These deficiencies highlight lapses in maintaining sanitary conditions in food preparation and storage areas.
Failure to Conduct Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to ensure that the required Quality Assurance Performance Improvement (QAPI) meetings were held quarterly and that all necessary members attended these meetings. Specifically, there was no documentation available to confirm that a QAPI meeting took place during the first quarter of 2024. Additionally, the sign-in sheet for the fourth quarter 2023 QAPI meeting, dated February 23, 2024, did not include the presence of an Infection Preventionist, which is a required attendee. The Director of Nursing confirmed the absence of the Infection Preventionist at this meeting and the lack of documentation for the first quarter 2024 meeting. The facility's policy mandates that QAPI meetings occur quarterly with specific attendees, including the Administrator, Director of Nursing, Infection Preventionist, and other key staff members.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to establish a comprehensive water management program to prevent the growth of Legionella and other waterborne pathogens in its water systems. The facility's documentation was lacking a risk evaluation to identify areas at risk for Legionella growth, protocols for routine testing, and interventions for when control limits are not met. The Clinical Director of Operations confirmed the absence of a risk assessment, routine testing, and planned interventions, attributing the oversight to the lack of a Maintenance Director on staff. This deficiency potentially affects all 99 residents residing in the facility.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to ensure that call light devices were within reach for four residents, leading to a deficiency in honoring residents' rights to be treated with respect and dignity. Resident 14, who has diagnoses including repeated falls, muscle weakness, and dementia, was found with their call light on the floor, out of reach. Resident 27, with a history of fractures and osteoarthritis, had their call light hanging on the bed rail, three to four feet away from their reach. Resident 77, diagnosed with malignant neoplasms and epilepsy, was asleep with their call light at the end of the bed, out of reach. Resident 95, with cognitive deficits and morbid obesity, reported being unable to reach their call light, which was also at the end of the bed. The observations were made on the same day, and a Licensed Practical Nurse (LPN) confirmed that call lights should be within residents' reach at all times. The LPN stated that staff should ensure call lights are accessible when starting their shifts and when returning residents to their rooms. The deficiency highlights a failure in the facility's protocol to ensure residents can easily access their call lights, which is crucial for their safety and ability to request assistance.
Facility Fails to Address Resident Laundry Concerns
Penalty
Summary
The facility failed to adequately address multiple concerns raised by the resident council and facility grievances regarding laundry services. During a Resident Council Meeting, five residents expressed dissatisfaction with the timeliness and cleanliness of their returned personal items and clothing. The meeting minutes from several months documented ongoing complaints about delayed returns, poorly organized closets, missing items, and clothes being returned dirty. Additionally, the facility's Grievance Log from February to June 2024 recorded numerous concerns about clothing not being returned promptly or at all. Observations revealed a large bin of personal items in the laundry room awaiting return to residents. The laundry attendant indicated that her dual role in housekeeping and laundry limited her ability to return items promptly, especially when CNAs brought full bins all at once. The Housekeeper/Laundry Supervisor noted that many clothes were unlabeled and undelivered, and the facility relied on contract services for laundry and housekeeping. Furthermore, the facility lacked a formal laundry policy, as confirmed by the administrator.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident, identified as R101, who was reviewed for discharge. R101 was admitted to the facility with diagnoses of Metabolic Encephalopathy and Unspecified Convulsions. Upon discharge, the discharge summary was found to be incomplete, with only two out of five sections filled out. The sections titled 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 were not fully completed, leaving critical information unrecorded. The facility's policy, dated November 2022, mandates that staff complete the Discharge Plan, Instructions, and Summary, which includes a recapitulation of the resident's stay. However, this was not adhered to in the case of R101. The Director of Nurses confirmed that if the discharge summary is not found under the resident assessment tab, it indicates it was not completed. This oversight in documentation was identified during an interview and record review, highlighting a lapse in the facility's discharge process.
Inaccurate Pressure Ulcer Treatment
Penalty
Summary
The facility failed to accurately provide treatment for a pressure ulcer for a resident reviewed for pressure ulcer treatments. The resident had physician orders to apply collagen to the wound bed of a right heel wound and a right medial ankle wound. During an observation, an LPN was seen applying approximately an inch in circumference of collagen on both the right heel wound and the right medial wound, covering not only the wound bed but also the peri-wound area. The Director of Nursing later stated that the LPN should have measured the wound bed to ensure the collagen was applied directly onto the wound bed without covering the peri-wound area, as per the physician's orders and the manufacturer's instructions for the collagen wound dressing.
Failure to Monitor PICC Line in Resident
Penalty
Summary
The facility failed to properly assess and monitor a Peripherally Inserted Central Catheter (PICC) for a resident diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of the Bladder. The resident, who is cognitively intact, returned from the hospital with a PICC line and new orders to start intravenous antibiotics after being admitted for a Urinary Tract Infection. However, the Physician Order Sheet did not include any orders regarding the PICC line, and the Medication or Treatment Administration Records indicated that the PICC line had not been routinely monitored by nursing staff since the resident's readmission. The resident reported that the nursing staff had not assessed the PICC line except during antibiotic administration. The Director of Nurses confirmed that intravenous sites should be monitored and flushed every shift, and staff should document the status of the intravenous site.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain effectively by not obtaining and administering prescribed pain medication. The resident, diagnosed with Bilateral Primary Osteoarthritis of the Knee, had a physician's order for Oxycodone-Acetaminophen to be administered every four hours for pain management. However, on a specific day, three doses were missed because the medication was unavailable. The LPN on duty discovered the shortage in the morning and contacted the doctor to place an order with the pharmacy. It was noted that the night shift nurses did not take action to call the doctor or pharmacy to replenish the medication. The Director of Nursing acknowledged that the medication cards should have prompted staff to reorder before running out and that the night shift should have used the stat safe box to provide an alternative pain medication until the original prescription was available.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment for a newly developed skin wound for a resident diagnosed with moderate protein-calorie malnutrition, muscle weakness, reduced mobility, and myasthenia gravis. The resident required substantial assistance with movements such as rolling, sitting, and standing. On June 14, 2024, a Nurse Skin Inspection Report documented the presence of redness, bloody drainage, and an open ulcer in the coccyx/sacrum/buttocks area. However, there was no documentation of any treatment or notification of the medical doctor on that date. Treatment for the wound did not commence until June 18, 2024, four days after the issue was identified. The Assistant Director of Nursing (ADON) stated that the Licensed Practical Nurse (LPN) should have informed the wound nurse and the medical doctor about the skin issue immediately. The LPN admitted to being busy and not reviewing the shower sheet, which led to the delay in addressing the skin issue. The facility's policy on pressure ulcer prevention requires immediate treatment to prevent further development of ulcers. The Administrator confirmed that any skin issue noted should prompt an immediate and thorough skin assessment by the nurse.
Resident Burned by Space Heater Due to Facility Oversight
Penalty
Summary
The facility failed to remove an electric space heater from a resident's room, resulting in the resident sustaining a burn injury. The resident, who is cognitively intact and requires assistance with transfers and activities of daily living, had purchased the heater after admission. The resident believed staff were aware of the heater's presence, as they would adjust it upon request. On the day of the incident, the heater was left on the floor, and the resident accidentally burned their leg while getting out of bed. The incident was reported to the Illinois Department of Public Health, and a medical doctor was notified. The resident received treatment for a fluid-filled blister and a scabbed burn area on the left lower leg. The facility administrator acknowledged that staff were unaware that electric heaters were prohibited, indicating a lack of communication and enforcement of safety policies within the facility.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving resident R3 who exhibited aggressive behaviors towards other residents. R3, who is cognitively intact and propels independently in a wheelchair, had documented incidents of hitting behaviors on multiple occasions. Despite these documented behaviors, R3's electronic medical record did not include an Abuse Risk Assessment. On several occasions, R3 physically assaulted other residents, including R7, R5, and R6, causing distress and potential harm. R7, who has multiple medical diagnoses and is cognitively intact, reported that R3 attempted to steal a personal item from her wheelchair and subsequently punched her when she resisted. R5, who is also cognitively intact and requires maximum staff assistance, was punched by R3 while waiting in the hallway. R6, who is severely cognitively impaired and dependent on staff for mobility, was also punched by R3 in a similar manner. These incidents occurred while R3 was being wheeled down the hallway by an LPN, who failed to remove other residents from R3's path, thereby exposing them to potential harm. Additionally, R4, who is severely cognitively impaired, was involved in a physical altercation with R3 in the dining room. R3 backed his wheelchair into R4's table, leading to a confrontation where R3 hit R4. The facility's staff failed to intervene appropriately to prevent these incidents, despite being aware of R3's aggressive behaviors. The facility's policies and procedures for abuse prevention were not adequately followed, resulting in multiple residents being subjected to physical abuse by R3.
Failure to Protect Residents from Abuse and Investigate Allegations
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident with known physical aggression and did not investigate allegations of abuse by both residents and staff. The facility's policy mandates that the Administrator or a designated person ensures a thorough investigation of alleged violations and takes steps to prevent further abuse. However, the facility did not adhere to this policy, resulting in multiple incidents of physical abuse and uninvestigated allegations. Specifically, a resident with known aggressive behavior (R3) was wheeled past other residents by an LPN, leading to physical altercations where R3 punched two other residents (R5 and R6). The Director of Nursing acknowledged that the LPN should have taken measures to prevent these incidents, such as removing other residents from the area or seeking additional staff assistance. Additionally, the facility did not conduct timely physical assessments or keep the aggressive resident away from others during the investigation process. Another incident involved a resident (R1) who reported feeling unsafe due to inappropriate behavior by a male CNA during a shower. The resident alleged that the CNA might have had an erection and went through her drawers, making her feel like he was going to steal from her. This allegation was reported to the facility's Director of Nursing and Administrator by an LPN at a local physician's office. Despite this, the Administrator did not consider the incident as abuse and did not initiate an investigation. The facility failed to provide documentation of any investigation into this allegation, and the Regional Clinical Nurse confirmed that the facility's policy required a complete investigation. The facility's failure to protect residents from abuse and to investigate allegations thoroughly affected five residents out of a sample of twelve. The incidents highlight significant lapses in following the facility's abuse prevention and prohibition policy, leading to unaddressed and uninvestigated abuse allegations. The lack of appropriate action and documentation underscores the facility's non-compliance with regulatory requirements for resident safety and abuse prevention.
Failure to Respect Resident's Personal Property
Penalty
Summary
The facility failed to ensure resident rights regarding personal property for one resident. The incident involved a CNA who was observed by another resident going through the first resident's drawers without permission, claiming to retrieve washcloths. The affected resident expressed discomfort with the CNA's actions. The Director of Nursing confirmed the grievance and acknowledged the CNA's actions. Both the Assistant Director of Nursing and the Regional Clinical Director of Operations agreed that staff should always ask for permission before accessing a resident's personal belongings.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy for one of twelve residents reviewed for abuse. The facility's abuse policy mandates that any allegations of abuse must be reported immediately to the Administrator, who is then responsible for ensuring a thorough investigation and taking steps to prevent further abuse. On May 6, 2024, a resident reported to an LPN at a local physician's office that a CNA at the facility made her feel unsafe. The LPN reported this to the facility immediately after the appointment. However, the Administrator decided that no abuse had occurred and did not investigate or report the allegation as required by the policy. Despite the resident's report, the CNA in question continued to work at the facility, as evidenced by the nursing schedule and the resident's statement. It was only later that the CNA was suspended pending investigation. The Regional Clinical Nurse and the Regional Director of Operations confirmed that the facility's policy was not followed in this case, as any allegation of abuse should have been investigated and reported immediately, and the accused individual should have been restricted from accessing the facility during the investigation.
Failure to Timely Report Allegations of Abuse and Resident Altercations
Penalty
Summary
The facility failed to report allegations of physical and potential sexual abuse timely to the State Agency for three residents. The facility's policy mandates that any allegations of abuse or neglect must be reported to the State Agency within two hours. However, an incident involving a male CNA who allegedly had an erection while giving a resident a shower and went through her drawers was not reported. The Administrator and Director of Nursing were informed of the incident, but the Administrator did not consider it abuse and failed to report it. There was no documentation of the incident, investigation, or report to the State Agency until the survey was conducted. Additionally, the facility did not report a resident-to-resident altercation involving three residents. An initial incident report documented an altercation between two residents, but the facility failed to report two other incidents where the same resident punched two other residents. The Administrator acknowledged the failure to report these incidents, which were witnessed by staff and documented in a written statement. The facility's policy requires immediate reporting and investigation of such incidents, which was not followed in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 169 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mattoon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Mattoon | 0.5 mi | ★★★★★ | 36 | 1 |
| Odd Fellow-rebekah Home | 1.4 mi | ★★★★★ | 20 | 0 |
| Charleston Rehab And Nursing | 10.9 mi | ★★★★★ | 21 | 0 |
| Heartland Senior Living | 11 mi | ★★★★★ | 4 | 0 |
| Hilltop Skilled Nsg & Rehab | 14.9 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.