Inspection·December 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of four (R1, R12, R13 and R14) of six residents reviewed for dignity from a total sample list of 15 residents. Findings include: 1.) The facility provided report to the State Agency dated 11/26/24 documents that on 11/19/24, R1 complained that he did not like the care provided to him by V15 Certified Nursing Assistant (CNA). The facility response documented that V15 CNA would not provide R1 with further care. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and that R1 is dependent on staff for activities of daily living. On 12/16/24 at 10:00AM, V15 CNA stated that he continues to provide care for R1, as directed by the nursing staff. On 12/16/24 at 1:00PM, R1 stated that V15 CNA still cares for him. R1 stated, They just do whatever they want. On 12/16/24 at 3:10PM, V1 Administrator stated that V15 CNA is not supposed to be providing care for R1 and that by doing so, R1's wishes are being disrespected. 2.) The facility provided report to the State Agency dated 11/15/24 documents that R12 complained that while in her room, V13 (Roommate's Boyfriend) walked in on her in a state of undress and did not immediately leave. R12's Minimum Data Set, dated [DATE] documents R12 is cognitively intact. R12's progress notes document discharge from the facility on 12/1/24. On 12/16/24 at 8:15AM, V14 CNA stated that she was in the area when the issue occurred and that she got to R12 as soon as R12 began to yell and removed V13 from the room. V14 CNA stated that she was able to calm R12 after that. V14 stated that nothing like that had ever occurred in the facility before, to her knowledge. On 12/16/24 at 9:15AM, V12 Social Services Director stated that she met with R12 multiple times after the incident and that R12 returned to her baseline. In the moment, R12 was very upset and (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 12/16/2024 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)