Health inspection·January 26, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to keep resident call buttons in an easily accessible area for four of five at risk residents (R2, R3, R4, R5) reviewed for call button accessibility on the sample list of five. Residents Affected - Some Findings Include: 1. R2's Medical Diagnoses List dated January 2025 documents R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Dysphagia, Weakness, Dementia, and Difficulty Walking. R2's Care Plan dated May 2024 documents R2 is at risk for falls and staff should keep her call light within reach and encourage her to use it. R2 also has a communication problem related to Dementia and staff should make sure R2's call light is within reach and avoid isolation. R2 requires two person staff assistance for transfers and toileting. On 1/26/25 at 1:40 PM R2 was laying in her bed. She was the only person in her room. R2 was wearing oxygen by nasal cannula and a wheelchair was parked near her bed. R2's special touch pad call button was laying at the foot of her bed completely out of her reach. 2. R3's Medical Diagnoses List dated January 2025 documents R3 is diagnosed with Unsteadiness on Feet, Dementia, and Dysphagia. R3's Care Plan dated January 2025 documents R3 is at risk for fall related to confusion and gait problems and staff are to keep his call light within reach and encourage him to use it. R3 also has a swallowing problem and should only eat with supervision. On 1/26/25 at 12:50 PM R3 was in the family room sitting in his wheelchair by himself. R3 was attempting to eat his noon meal which consisted of pureed food. There was no access to a call button in R3's reach and no staff supervising R3 while he was eating. When this surveyor entered the room, R3 began to yell out and was attempting to communicate but could not be understood. Staff did not come in the room to attend to R3 for approximately 15 minutes. On 1/26/25 at 2:45 PM R3 was laying in his bed asleep. There was a fall mat on the floor next to his bed and R3's call button was coiled on the other bed completely out of R3's reach. 3. R4's Medical Diagnoses List dated January 2025 documents R4 is diagnosed with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Vascular Dementia, and Difficulty Walking. R4's Care Plan dated December 2024 documents R4 is at risk for falls related to deconditioning, Page 1 of 2 145480 145480 01/26/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gait/balance problems, history of falls, COPD (Chronic Obstructive Pulmonary Disease), and CHF (Congestive Heart Failure). Staff should keep R4's call button within reach and remind her to use it. On 1/26/25 at 2:18 PM R4 was sitting in her recliner in her room by herself. R4 had slid down in her recliner and her feet were hanging off the footrest. Her recliner was in the middle of two beds. One call button was coiled on one of the beds and the other call light was on the other side of R4's recliner on the floor. On 1/26/25 at 2:18 PM R4 stated she would use her call button to call for help but she couldn't find it. R4 stated she always slides down in her recliner. 4. R5's Medical Diagnoses List dated January 2025 documents R5 is diagnosed with Dementia, History of Falls, Weakness, and Difficulty Walking. R5's Care Plan dated December 2024 documents R5 is at risk for falls related to dementia, muscle weakness, confusion, impulsiveness, and incontinence. Staff should keep R5's call button within reach. On 1/26/25 at 2:10 PM R5 was asleep in his bed. His wheelchair with mechanical lift sling was near his bed. R5's call button was on the floor beside his wheelchair, far from R5's reach. On 1/26/25 at 2:47 PM V3 Assistant Director of Nurses (ADON) confirmed all residents should have a call button within their reach when they are in bed or in a room alone and might need the assistance of staff. V3 confirmed some residents are at higher risk for accidents- for example residents that are at risk for choking while eating, those that need assistance to safely transfer, and those that are unaware of their own physical boundaries. 145480 Page 2 of 2