F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to revise resident's care plans to accurately
reflect resident's current status. This failure affects two residents (R1 and R3) out of the sample of three
reviewed for falls.
Findings include:
1. R1's Care Plan for Fall Prevention documents an intervention to Ensure personal items are in reach,
initiated 3/10/23, and a second intervention to Make sure (R1) has mirror in reach, initiated 9/2/23.
On 5/6/25 at 10:35 am, 11:00 AM, 12:55 PM, R1 did not have any personal items, including a mirror, in
view in her room.
On 5/6/25 at 1:45 PM, V4, Licensed Practical Nurse, stated R1 doesn't really have any personal items, and
she hasn't seen R1 with a mirror in a long time.
On 5/6/25 at 1:55 PM, V7, Registered Nurse, stated that R1 used to keep her purse, hairbrush, make up,
and mirror with her in bed and would sit and do her make up and brush her hair. V7 further stated R1 hasn't
been able to do that for a long time.
2. R3's Care Plan for Fall Prevention documents an intervention to Educate staff to assist with dentures,
initiated 12/26/24.
On 5/7/25 at 9:50 AM, R1 did not have any dentures. R1 did have natural teeth. At this date and time, R1
stated staff do not help her with dentures because she doesn't have any dentures, she has her own teeth.
On 5/7/25 at 10:38 AM, V4, Licensed Practical Nurse, checked R1's Nursing assessment dated [DATE] and
stated the assessment documents R1 has natural teeth.
R1's Nutritional assessment dated [DATE], and Nursing assessment dated [DATE], both document R1 has
natural teeth and no dentures.
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 2
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
05/07/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and record review, the facility failed to conduct safe transfers in
accordance with a resident's care plan (R1), and failed to implement fall prevention interventions according
to a resident's care plan (R2). These failures affect two residents (R1 and R2) out of the sample list of three
reviewed for falls.
Findings include:
1. R1's Fall Risk assessments dated 4/15/25 and 4/19/25 document R1 is at high risk for falls.
R1's Nurses Progress Notes dated 4/15/25 document R1 experienced a fall in the facility.
R1's current Care Plan for Fall Prevention documents an intervention for Staff re-educated to ensure they
are using an appropriate number of staff during all transfers, initiated 11/3/22. This same Care Plan for
Activities of Daily Living documents R1 requires two staff participation for transfers, initiated 9/30/20.
On 5/6/25 at 3:46 PM, V8, Certified Nursing Assistant, stated R1 is not steady at all standing up. V8 stated
when she transfers R1, she has R1 wrap R1's arms around V8's neck, and since R1 can not stand steadily,
V8 has to do all the work of standing R1 and conducting the transfer from the bed to the wheelchair. V8
confirmed she conducts these transfers by herself alone.
On 5/7/25 at 1:45 PM, V1, Administrator, confirmed there was an expectation for the nurses and certified
nursing assistants to be familiar with resident's care plans, especially the residents' transfer status. V1
stated when she heard about the transfers conducted by V8 with R1, she immediately conducted a staff
education meeting about the topic of appropriate transfers.
2. R2's Fall Risk Assessments dated 4/23/25, 4/20/25, 4/1/25, 3/25/25, and 3/22/25 document R2 was at
high risk for falls.
R2's Nurses Progress Notes dated 4/23/25, 4/20/25, 3/22/25, and 2/6/25 all document R2 has a history of
multiple falls while residing in the facility.
R2's current Care Plan for fall prevention documents an intervention as Call don't fall sign to be placed in
R2's room, initiated 8/17/24.
On 5/6/25 at 12:56 PM, there was not a call don't fall sign located in R2's room. On 5/6/25 at 1:10 PM, V5,
Licensed Practical Nurse, confirmed there was not a call don't fall sign in R2's room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145480
If continuation sheet
Page 2 of 2
