Health inspection·September 17, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination of one (R66) resident's infected Diabetic Foot Ulcers out of two residents reviewed for skin conditions in a sample list of 41 residents.Findings include:R66's Minimum Data Set (MDS) dated [DATE] documents R66 as cognitively intact. This same MDS documents R66 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R66's Physician Order Sheet (POS) dated September 2025 documents a physician order to cleanse R66's Left Lateral Diabetic Foot Ulcer (DFU) with wound cleanser, apply Santyl (chemical debrider) 250 units/Gram to wound bed, cover with Calcium Alginate and dry dressing daily. This same POS documents a physician order to cleanse R66's Right Second Toe DFU with wound cleanser, apply calcium alginate and dry dressing daily. On 9/17/25 at 10:30 AM V20 Licensed Practical Nurse (LPN) completed wound care for R66's Left Lateral Foot Diabetic Foot Ulcer (DFU) Right Second Toe DFU. R66's Left Lateral Foot Diabetic ulcer showed a dime sized open reddened area with raised white periwound. R66's Left Lateral Foot and Right Second Toe open wounds appeared wet with drainage. R66's dressings were not in place prior to the dressing changes on R66's Left Lateral Foot and Right Second Toe. V20 LPN placed paper towels from R66's room onto R66's bedside table that had not been cleaned off. R66's chemical debriding ointment, Calcium Alginate and scissors were placed directly on the contaminated bedside table. V20 LPN used the same contaminated scissors to cut R66's Calcium Alginate to match the wound size. V20 LPN applied R66's chemical debriding ointment and Calcium Alginate directly on R66's open wounds. On 9/16/25 at 1:00 PM V14 Licensed Practical Nurse (LPN) stated the facility obtained a culture of R66's Left Lateral Foot DFU wound last week and R66 was started on an antibiotic for a wound infection. On 9/17/25 at 10:55 AM V20 Licensed Practical Nurse (LPN) confirmed the wound supplies were not placed on the clean field for R66's dressing changes. V20 LPN stated she did not disinfect R66's bedside table prior to placing R66's wound supplies on the bedside table. On 9/17/25 at 11:50 AM V23 Clinical Reimbursement Specialist stated she and V3 Regional Clinical Nurse (RCN) have looked for a policy on clean dressing changes and are unable to find one. Residents Affected - Few Page 1 of 9 145480 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during urinary catheter care for one (R29) resident out of two residents reviewed for catheter care in a sample list of 41 residents. Findings include:R29's Minimum Data Set (MDS) dated [DATE] documents R29 as cognitively intact. This same MDS documents R29 as requiring maximum assistance from staff for personal hygiene and is dependent on staff for toileting and dressing. On 9/16/25 at 2:10 PM V18 and V19 Certified Nurse Aides (CNA) completed urinary catheter care for R29. V18 CNA prepared a basin of soapy water for use in providing catheter care. V18 CNA did not rinse R29's front or rear perineal areas after washing with soapy water. R29 was incontinent of bowel. V18 CNA did not change gloves or perform hand hygiene after cleansing R29's front and rear perineal areas and before applying a new incontinence brief. R29 was wearing a urinary catheter leg drainage bag which was pulled taunt during positioning of R29. V18 did not ensure R29's urinary catheter was held secure while providing perineal care. V18 did not wipe R29's urinary catheter off during catheter care. V18 CNA did not apply barrier cream after providing perineal/catheter care for R29. On 9/16/25 at 2:30 PM V18 Certified Nurse Aide (CNA) stated she should have changed her gloves after cleansing R29's perianal area and prior to applying a new incontinence brief. V18 CNA stated not rinsing the soap off could cause irritation to R29's skin. V18 CNA stated R29's urinary catheter became ‘tight' when V18 asked R29 to move her leg. V18 stated she should have adjusted the tubing or secured it differently to ensure it wasn't pulled. On 9/16/25 at 3:00 PM V1 Administrator stated staff should follow the policy when providing all cares including Perineal care and urinary catheter care. V1 Administrator stated staff who cross contaminate could put the residents at a higher risk of infection.On 9/17/25 at 11:15 AM V23 Clinical Reimbursement Specialist stated the facility does not have a specific policy for Perineal care. V23 stated the expectation is for staff to follow standard precautions and standard of care. The facility policy titled Catheter Care, Urinary revised December 2024 documents staff should use Standard Precautions when handling or manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. Staff should fill a wash basin with warm water and place the wash basin within easy reach. Use a washcloth with warm water and soap to cleanse the labia. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site outward. 145480 Page 2 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to properly maintain and store respiratory equipment. This failure has the potential to affect one of one residents (R3) reviewed for respiratory care on the sample list of 41. Findings Include: The facility's Tracheostomy Care policy dated [DATE] documents a replacement tracheostomy tube must always be available at the bedside. The same policy documents a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must always be available at the bedside. The same policy documents an emergency tracheostomy set up should be kept at the resident's bedside. R3's Medical Diagnoses dated [DATE] documents R3 is diagnosed with Anoxic Brain Damage, Anxiety Disorder, Paraplegia, Dependence on Supplemental Oxygen, and Tracheostomy Status. R3's Physician Order Sheet dated [DATE] documents facility staff are to maintain suction set up, an emergency bag valve mask, and a replacement tracheostomy tube of equal size and one size down at R3's bedside at all times. R3's Care Plan dated [DATE] documents R3 has a Tracheostomy related to Impaired Breathing Mechanics due to an Anoxic Brain Energy. Interventions include an emergency bag valve mask, humidification, oxygen tubing, and suction machine at R3's bedside. Interventions should also include a replacement tracheostomy tube of equal size, and one size down, maintained at the bedside. On [DATE] at 1:15 PM there were no tracheostomy tubes at R3's bedside. The emergency bag valve mask was stored in a ripped belongs bag with a date of [DATE] and the lubricant and other supplies in the bad expired [DATE]. There was an irrigation tray with an expiration date of [DATE] and the container of sterile water, which was more than hallway gone, was not marked with the date it was opened. On [DATE] at 1:31 PM V1 Administrator and V3 Director of Clinical both confirmed extra tracheostomy tubes need to be kept at R3's bedside readily available, opened containers of multiuse liquids need to be marked with the date they were opened, and all supplies for emergencies and tracheostomy maintenance need to be checked for expiration and integrity on a regular basis. Residents Affected - Few 145480 Page 3 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure a medication error rate less than 5%. This error effects two (R33, R34) residents out of six residents reviewed for medication administration in a sample list of 41 residents. The facility medication error rate was 7.41% based on two medication errors out of 27 opportunities completed.Findings include:R33's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 6/19/25 to administer Buspirone Hydrochloride (HCl) (Buspar) Oral Tablet 10 MG (Buspirone HCl) daily. R33's Electronic Medical Record (EMR) documents R33 resides in bed number two. R34's Physician Order Sheet (POS) dated September 2025 does not document a physician order for Buspar 10 mg. R34's EMR documents R34 resides in bed number one. R34's Nurse Progress Note dated 9/16/25 at 1:47 PM documents R34 received roommate's (R33) scheduled Buspirone 10 milligrams (mg) (9/15/25) at noon. On 9/15/25 at 12:39 PM R33's name plate outside her door showed R33's name with a ‘D' next to it. R34's name plate outside the same door showed R34's name with a ‘W' next to it. On 9/15/25 at 12:40 PM V8 Licensed Practical Nurse (LPN) prepared R33's Buspar 10 milligrams (mg) at the medication cart outside of R33's room. R33 and R34 share the same last name and share a room. V8 LPN administered R33's Buspar 10 mg to the resident (R34) residing in the bed by the door. V8 Licensed Practical Nurse (LPN) administered R33's Buspar 10 milligrams (mg) to R33's roommate (R34). V8 LPN did not administer R33's physician ordered Buspar 10 mg to R33. On 9/16/25 at 1:00 PM V12 Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated R33 resides in the bed by the window and R34 resides in the bed by the door. V12 ADON confirmed R33's Buspar 10 mg was given to R34 in error. On 9/16/25 at 1:35 PM V15 Licensed Practical Nurse (LPN) stated the residents' names and bed position are located outside each door on their nameplate. V15 LPN stated the staff know the resident by the nameplate. V15 LPN stated the nameplate and the EMR should match. On 9/16/25 at 1:37 PM V16 Certified Nurse Aide (CNA) stated she was unaware of bed ‘one' or bed ‘two'. V16 states the residents are known and referred to by ‘D' which stands for the bed by the door or ‘W' which stands for the bed by the window. On 9/16/25 at 2:00 PM V3 Regional Clinical Nurse (RCN) stated all nurses should verify they are administering the correct medication to the correct resident. V3 RCN stated a medication error report would be completed along with notification to (R33, R34) representative and Physician. The facility policy titled Administration of Medications revised April 2021 documents immediately after a drug us ingested it should be recorded on the Medication Administration Record (MAR). If for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record. Nursing staff will report immediately to the attending physician any medication errors, or adverse drug reactions. Residents Affected - Few 145480 Page 4 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to properly dispose of medications for one (R61) resident out of six residents reviewed for medication administration in a sample list of 41 residents. Findings include: R61's Physician Order Sheet (POS) dated September 2025 documents a physician order to administer Loratadine 10 milligrams (mg) daily. On 9/16/25 at 8:00 AM V16 Licensed Practical Nurse (LPN) prepared R61's medications for administration. V16 LPN dropped R61's Loratadine 10 milligrams (mg) directly onto the top of the medication cart. V16 LPN used her bare hand to pick up the dropped Loratadine and put it into the garbage can attached to the medication cart. V16 LPN replaced R61's Loratadine 10 mg. V16 LPN administered R61's medications without washing her hands or performing hand hygiene after disposing of R61's dropped Loratadine medication. On 9/16/25 at 8:10 AM V16 Licensed Practical Nurse (LPN) stated she should have used gloves to pick up R61's dropped Loratadine 10 mg. V16 LPN stated the facility has a bottle of chemical that is used for disposing of medications. V16 LPN stated she should not have disposed of R61's medication in the open garbage can. On 9/16/25 at 9:15 AM V3 Regional Clinical Nurse (RCN) stated the facility nurses are supposed to use a glove when handling all medications. V3 stated medications should never be disposed of in an open garbage can. V3 RCN stated the facility has a bottle of chemical agent that destroys medications that is kept in the nursing medication room. The facility policy titled Storage and Return of Drugs revised April 2021 documents Residents' medications shall be properly labeled and stored at or near the nurse's station in a locked cabinet, a locked medication room, or in one or more locked mobile medications carts of satisfactory design for such storage. All mobile medication carts shall be under the visual control for the responsible nurse at all times when not stored either in a locked room or otherwise made immobile. 145480 Page 5 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statementA. Based upon record review and interview, the facility failed to follow infection control policy and procedure during communicable disease outbreak. This failure had the potential to affect all 94 residents residing at facility.B. Based upon observation, interview and record review the facility failed to place a resident in contact isolation with Methicillin-Resistant Staphylococcus Aureus (MRSA) for one (R66) resident and operationalize its policy to wear proper PPE (personal protective equipment) during medication administration for one (R34) resident reviewed on contact isolation with Methicillin-Resistant Staphylococcus Aureus (MRSA) on a sample list of 41.Findings include:a. Facility Census titled Resident Census and dated 9/14/25 documents 94 residents currently in house. Residents Affected - Many Infection Surveillance Monthly Report dated June 2025 documents 10 residents with respiratory infections, 5 residents with Pneumonia, 5 residents with Covid 19, and 1 resident with bronchitis. All 21 residents had similar symptoms and were placed on droplet isolation precautions. On 9/16/25 at 11:15 AM V12, Assistant Director Of Nursing(ADON)/Infection Preventionist(IP) stated she did not notify local health department regarding upper respiratory infection outbreak within the facility and no emergency quality meeting was held to identify source, trend, or plan of action. On 9/16/25 at 11:35 AM V1 Administrator stated during outbreak, the expectation would be to follow written policy guidelines. At 1:45 PM on 9/16/25, V3 Regional Nurse, stated no formal Prevention Identification Plan had been conducted regarding the respiratory outbreak. Facility's Infection Prevention and Control Program dated 2019 documents the IP is to conduct surveillance and monitoring of all organisms causing infections, antibiotic-resistant organisms, and transmission of organisms between residents and report these finding to local public health department. b. 1. R66's Minimum Data Set (MDS) dated [DATE] documents R66 as cognitively intact. This same MDS documents R66 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R66's Care plan intervention dated 7/18/2025 documents R66 is on antibiotic therapy due to wound infection. R66's CarePlan did not include a focus area, goal nor intervention for R66 requiring isolation precautions. On 9/14/25 at 10:45 AM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. There was no Personal Protective Equipment (PPE) supplies easily accessible. On 9/15/25 at 2:15 PM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. There was no Personal Protective Equipment (PPE) supplies easily accessible. On 9/15/25 at 9:30 AM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. There was no Personal Protective Equipment (PPE) supplies 145480 Page 6 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0880 easily accessible. Level of Harm - Minimal harm or potential for actual harm On 9/17/25 at 9:00 AM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. R66 had PPE available from a container attached to his room door. Residents Affected - Many On 9/15/25 at 1:20 PM V12 Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated R66 does not require any type of isolation precautions for his open, infected Left Lateral Foot Diabetic Foot Ulcer due to the size of his wound was smaller than a band-aid. On 9/16/25 at 1:00 PM V14 Licensed Practical Nurse (LPN) stated R66 has a Diabetic wound ulcer on his Left Foot. V14 stated the facility obtained a culture of R66's wound last week and R66 was started on an antibiotic. On 9/16/25 at 2:30 PM V10 Licensed Practical Nurse (LPN) stated she completed R66's Left Lateral Foot Diabetic Foot Ulcer treatment without wearing the proper Personal Protective Equipment (PPE). V10 LPN stated R66 did not have any isolation precaution signs on his room door so she was unaware R66 was on isolation precautions. On 9/17/25 at 11:05 AM V25 (R66) Power of Attorney (POA) stated V25 visits with R66 daily from before breakfast to after lunch. V25 stated the staff 'just started' wearing PPE today (9/17/25). V25 stated she was informed last week of R66's wound infection in his Left Lateral Foot. V25 stated the staff have been changing R66's dressings to his Left Foot without 'all that' (PPE). The undated facility policy titled Infection Prevention and Control Manual-Enhanced Barrier Precautions documents Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi Drug Resistant Organism (MDRO) as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and may residents colonized with a MDRO are asymptomatic or not presently known to be colonized. 2. R34's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 9/9/25 for R34 to be placed on Contact Isolation due to Methicillin Resistant Staphylococcus Aureus (MRSA) in her wound and Extended-spectrum Beta Lactamase (ESBL) in her urine. On 9/15/25 at 12:28 PM R34's room door posted a sign that read 'Contact Precautions'. R34's room door had a Personal Protective Equipment (PPE) storage container hanging over R34's door so that staff could access PPE from the outside of R34's room. V8 Licensed Practical Nurse (LPN) administered medication to R34 without wearing gown and/or gloves. On 9/16/25 at 1:50 PM V12 Assistant Director of Nurses (ADON)/Infection Preventionist (IP) stated staff should wear the appropriate Personal Protective Equipment (PPE) when caring for a resident on Contact Isolation. The facility policy titled Infection Prevention and Control Manual Transmission-Based Precautions Contact Precautions dated 2019 documents in addition to Standard Precautions, use Contact Precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or be indirect contact (touching) 145480 Page 7 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0880 Level of Harm - Minimal harm or potential for actual harm with environmental surfaces or contaminated resident care equipment. In addition to wearing gloves as outlined under Standard Precautions, clean, nonsterile gloves are worn when providing direct care to residents. [NAME] gown prior to entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the resident care environment. Residents Affected - Many 145480 Page 8 of 9 145480 09/17/2025 Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain essential equipment to ensure a safe operating environment in a medication room. This failure has the potential to affect all 94 residents residing in the facility. Findings include:The facility daily census dated 9/14/25 documents 94 residents reside in the facility. 1.On 9/15/25 at 12:30 PM V8 Licensed Practical Nurse (LPN) disposed of R33's medication in the [NAME] hall nurses medication room. V8 LPN applied soap to her hands then turned the handles on the facility sink to turn on the water. No water flowed from either the hot or cold water sides. V8 LPN stated the nurses medication room should have a working sink for her to wash her hands when needed. V8 stated she works on another hall also and doesn't have time to ‘run from hall to hall to find a working sink'. On 9/15/25 at 12:45 PM V6 Maintenance Director attempted to turn on the hot and cold sides of the water in the [NAME] hall nurses medication room. There was no water that flowed from either side. V6 Maintenance Director opened up the cabinets underneath the sink and attempted to fix the issue. On 9/15/25 at 12:55 PM V6 Maintenance Director stated the pipes leak underneath the sink as he was attempting to fix the sink. V6 Maintenance Director stated he was not aware of the sink not working on this hall and does not know who shut the water off. On 9/15/25 at 1:40 PM V1 Administrator stated each nurses station should have a functional sink with both hot and cold running water. V1 Administrator stated the [NAME] hall sink will be fixed as soon as possible. 2. On 9/15/25 at 12:35 PM The [NAME] hall nurses medication room showed electrical cords that stretched from the facility's (medication management machine) sitting in the corner, over the countertops, behind and touching the faucet and were plugged into a wall outlet on the opposite side of the sink. On 9/15/25 at 12:47 PM V6 Maintenance Director stated electrical cords should not be that close to a running water source. V6 Maintenance Director stated the sink does not currently work but if it did, this could be a very dangerous situation. V6 stated any staff member could turn the water back on from underneath the sink. On 9/15/25 at 1:42 PM V1 Administrator stated the facility should not have electrical cords near a water source. V1 Administrator stated ‘electricity and water do not mix'. V1 Administrator stated this situation would be ‘handled quickly'. V1 Administrator stated she is not aware of a facility policy for these issues but the expectation would be to have a functional sink in each nurses medication room and not have electrical cords laying against the faucet of a sink that are also plugged into the wall outlet. Residents Affected - Many 145480 Page 9 of 9