Health inspection·October 25, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident and mental abuse by a staff member. This failure affected three of four residents (R1, R3, R4) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Abuse means the willful infliction of injury, intimidation or punishment resulting in physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident. Mental abuse includes but is not limited to threats of punishment or deprivation. 1. The Abuse Investigation Summary dated 10/9/24 documents R1 reported V7 Certified Nurses Assistant (CNA) made statements to R1 that were inappropriate and threatening in tone. V9 Admissions' statement dated 10/9/24 documents R1's Wife (V17) reported to her that V7 CNA told R1 that if he didn't stop putting on his call light she was going to beat him. R1's Medical Diagnoses sheet dated October 2024 documents R1 is diagnosed with Cerebral Infarction, Muscle Weakness, Difficulty Walking, and Spine Fusion. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. On 10/24/24 at 3:57 PM R1 stated on the night of 10/8/24 V7 CNA came into his room three times to answer his call light. V7 had an attitude that he continued to put on his call light when his needs were not being met by the nursing staff. R1 stated V7 CNA came into his room and told him if he did not stop putting on his call light, she would beat him half to death. V7 then left the room and did not return. R1 stated she had an attitude the entire shift but she should not be making threatening remarks to residents. R1 stated V7 CNA should not be in a caring profession if she cannot be professional or does not actually care about the residents. R1 stated he never wants V7 to care for him again. On 10/25/24 at 2:00 PM V1 Administrator confirmed V7 CNA threatening R1 with physical violence if he did not quit using the call light is not acceptable behavior and is not the behavior the facility (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145480 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)