Mattoon Rehab & HCC

In the surveyor’s words

From the most serious findings on record at Mattoon Rehab & HCC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Nov 30, 2022

  Based on interview and record review the facility failed to identify, assess, report and treat a facility-acquired sacral pressure ulcer for R1. The facility failed to provide daily cares related to preserving intact skin, including cleansing, incontinence care, repositioning, and individualized pressure relieving devices to promote healing for a resident. Significant change notifications were not made to obtain treatment and implement targeted interventions to prevent the development and worsening of a stage four pressure ulcer for a resident. This failure affects one (R1) of three residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF600Jul 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure three (R9, R12, R18) of six residents reviewed for abuse remained free from verbal, mental, and physical abuse. This failure resulted in the loss of dignity and the potential for humiliation and emotional distress for R9, fear and ongoing psychosocial distress for R18, and abusive behavior by R12 toward another resident. Findings include: 1. On 05/21/2026 at approximately 5:50 PM, V15 Dietary Aide observed V16 Certified Nursing Assistant (CNA) standing in the hallway on the [NAME] Hall within hearing distance of R9 during evening meal service. V15 stated the hallway was occupied by residents, staff, and dietary personnel. […]

• Actual harm, isolatedF760May 19, 2026

  Based on interview and record review, the facility failed to follow physician orders for insulin administration for one (R3) of three residents reviewed for quality of care in a sample of 69. This failure resulted in R3 receiving a dose of insulin via a syringe while simultaneously receiving insulin from an insulin pump, causing hypoglycemia, decline in condition, and hospitalization. This past noncompliance occurred from 4/2/2026 to 4/6/2026.Findings include: R3's Census, within the facility's Electronic Health Record, documents an initial admission date to the facility as 3/18/2026.R3's undated Care Plan documents a readmission date to the facility as 4/6/2026 with the following diagnoses: Acute Kidney Failure, Hyperkalemia, Chronic Kidney Disease, Stage 3, Muscle Weakness, Need For… […]

• Actual harm, isolatedF684Feb 25, 2026

  Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review the facility failed to complete wound assessments, follow physician's orders, implement infection control during wound care for one of 15 residents (R5) reviewed for wounds in the sample list of 15. These failures resulted in deterioration of R5's wounds and infection that required hospitalization and intravenous antibiotics. B. Based on interview and record review the facility failed to develop and implement interventions for preventing skin tears for one of five residents (R6) reviewed for wounds in the sample list of 15. […]

• Actual harm, isolatedF760Apr 7, 2025

  Based on interview and record review the facility failed to ensure that residents were administered medications as prescribed per phyisican orders for (R1, R2, R3 & R4) of four residents reviewed for medication administration. This failure resulted in R1 being administered medications prescribed for another resident, to include a large dose of Morphine (Opiod Narcotic medication), resulting in R1 experiencing side effects for multiple days after and also requiring the administration of Narcan (Opiod Reversal Agent). […]