Mattoon Rehab & Hcc
MATTOON REHAB & HCC in MATTOON, IL — inspection on February 25, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
treatments ended 12/22/25 once R5's wounds deteriorated and started draining copious green
competencies for V12. V12 stated R5 was not on Transmission Based Precautions or EBP and V12 did
perform hand washing, remove outer leg wraps, apply gloves and remove wound dressings, change gloves, cleanse wounds with wound cleanser, change gloves apply clean dressings and wrap with gauze. V12 stated hand hygiene is done during the treatment only if hands are visibly soiled, otherwise just done before/after the treatment. V12 stated R5's orders were entered for three times weekly, V12 is not in the facility daily, and nursing staff should have clarified the order. On 2/19/26 at 3:09 PM V6 stated V12 was doing R5's wound treatments but then we changed that because the treatments should be done by a nurse and the nurses are responsible for assessing wounds during each treatment. V6 confirmed R5 did not have documented wound assessments after 12/12/25 until 1/2/26, besides 12/30/25 when R5 refused and no follow up attempts were documented. On 2/23/26 at 2:51 PM V2 DON stated V2 received a call from V15 Wound Clinic Nurse Practitioner reporting R5's wound dressings had not been changed. V2 confirmed there was no documentation that the treatments were administered. V2 stated ideally the treatment orders should have been on the TAR and the nurses should have taken over R5's wound care once V12 stopped. V2 stated the wound team is responsible for assessing wounds weekly. On 2/24/26 at 4:10 PM V2 stated during wound care gloves should be changed when moving from dirty to clean and hand hygiene performed with each glove change, including after removing dressings and after cleaning wounds. V2 stated an alcohol-based hand sanitizer can be used when hands are not visibly soiled. On 2/25/26 at 10:20 AM V2 stated EBP is implemented for open wounds. V2 confirmed a gown should be worn during wound care as part of EBP. B ) R6's MDS dated [DATE] documents R6 has severe cognitive impairment.R6's incident report dated 1/22/26 at 1:23 PM documents R6 had skin tears found to left lower leg and shin. R6 stated she hit her leg on the bed. R6 was sitting in her wheelchair and is able to self-propel.
R6's incident report dated 1/27/26 at 7:42 PM documents R6 had skin tear to left knee. R6 stated R6 bumped her knee. R6 was sitting in a wheelchair and is able to self-propel around her room.
There is no documentation in R6's medical record that interventions were developed/implemented to protect skin from additional skin tears following these incidents.On 2/25/26 at 10:20 AM V2 DON confirmed there were no documented skin interventions developed and implemented after R6's skin tears.
145480 02/25/2026
Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938
sacrum, shin and greater trochanter that weren't there the day prior and R1 wasn't eating or drinking.
and was noncompliant with floating heels. V10 stated R1 required two staff assist for transfers and
CNA charting and care plan for pressure relieving interventions. On 2/23/26 at 11:17 AM V6 LPN/Wound Nurse stated pressure relieving interventions are documented on the care plan and use of pressure relieving boots are documented on the TAR. V6 confirmed R1's care plan does not include the need for repositioning/turning or the frequency or pressure relieving interventions for feet prior to 12/24/25. V6 stated the standard of care is to float heels and reposition at least every two hours. V6 stated R1's left ankle pressure ulcer was facility acquired and identified on 12/24/25 and pressure relieving boots were initiated that day. V6 stated V6 rounded with V27 on 1/19/26 and R1 did not have any new wounds at that time. V6 stated the next day V6 was notified to come and assess R1 who had three more deep tissue injuries related to pressure. V6 stated R1 was overall declining and was less active. On 2/25/26 at 11:32 AM V6 stated R1's facility acquired left ankle pressure ulcer was identified during wound rounds on 1/12/26, was unstageable and covered with eschar.
The type of pressure relieving mattress depends on the location of the wound and air mattresses are used for stage three or four but leaves that up to the provider to decide. V6 stated we try to float heels or use pressure relieving boots prior to changing to an air mattress/alternating pressure mattress. V6 stated V6 did not discuss the use of this type of mattress with a provider since pressure relieving boots were in place. V6 stated V6 did not realize that the facility's standard pressure relieving mattresses are only recommended for up to stage two pressure ulcers. On 2/25/26 at 9:10 AM V2 Director of Nursing confirmed R1's pressure relieving boots were not resumed on R1's TAR after 1/8/26 and should have been.
The undated manufacturer's information for the facility's flip foam pressure relieving mattress, provided by V1 Administrator, documents this mattress may be appropriate for up to stage two pressure wounds but should be based on a resident specific assessment.
145480 02/25/2026
Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938
statements but does not identify the last time R14 was toileted prior to this fall.
The interdisciplinary
intervention was nonskid grip strips next to bed. R14's Fall Report dated 2/3/26 at 4:57 AM
the floor on his left side with wheelchair foot pedal underneath R14, and wheelchair was tipped up behind R14. R14 had a skin tear to left chest.
This fall investigation contains staff interviews but does not identify if R14 had a nonskid mat in R14's wheelchair.
The interdisciplinary note documents R14 was in the hallway and attempted to move his wheelchair forward, R14 fell out of the wheelchair and landed on the floor. R14's care plan was updated to replace the nonskid mat in the wheelchair. R14's Nursing Note dated 2/19/2026 at 2:25 PM documents nurse called to R14's room and R14 was sitting on the floor mat on the floor next to R14's bed. CNA (V38) was transferring R14 from wheelchair to bed, V38's foot got caught on floor mat, V38 was unable to regain balance and sat R14 on the floor.
R14 bumped right elbow on wheelchair and received a crescent shaped skin tear. On 2/24/26 at 10:18 AM V41 CNA stated V41 had just gotten R14 up a few minutes prior to the fall on 12/19/25 and V41 could not recall if a nonskid mat was in R14's wheelchair when R14 fell. On 2/24/26 at 1:07 PM V38 CNA stated last week V38 transferred R14 with gait belt to bed. V38 stated V38 did not pick up the floor mat, V38's foot caught on the mat causing V38 to lose her balance and V38 lowered R14 to the floor. V38 stated R14 bumped his arm on the wheelchair causing a skin tear to right elbow. V38 stated V38 should have picked up the floor mat to prevent the fall. On 2/24/26 at 4:10 PM V2 DON confirmed all documentation was provided for R14's fall investigations. V2 stated R14 fell on 2/3/26 and the nonskid mat was replaced, V2 could not recall if it was because the nonskid mat wasn't in place or if it was because it was worn. V2 confirmed this information is not documented in R14's fall investigation. V2 stated this past Thursday R14 fell during staff assisted transfer and post fall intervention was to pick up the fall mat when R14 is out of bed.
145480 02/25/2026
Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938
services of a licensed pharmacist.
destroy controlled medications for three of four residents (R7, R9, R15) reviewed for controlled
Policy dated December 2024 documents: Controlled substances should be destroyed with a licensed nurse and licensed professional.
The destruction, quantity destroyed, and date should be documented on the controlled medication count sheet and signed by the nurse and the witnessing licensed professional.The facility's Controlled Substance Policy dated December 2024 documents the nurse will sign the controlled medication out on the Controlled Substance Proof of Use Form immediately and document the medication on the Medication Administration Record (MAR) immediately after administration.1.) R9's Controlled Substance Record for Diazepam 2 milligrams (mg) documents single doses were dispensed on 1/25/26, 1/30/26, 2/2/26 and 2/8/26 between 10:30 PM and 12:30 AM, signed by V31 Licensed Practical Nurse (LPN).
These entries are not recorded on R9's January and February 2026 MARs as there is no active order entered after 1/22/26. R9's Census documents R9 discharged from the facility on 2/14/26.On 2/18/26 at 10:16 AM the controlled medications in the medication cart on the Lotus Hall were checked with V10 LPN. R9's Diazepam cards contained six remaining tablets and a full card of 14 tablets. V10 stated R9 discharged to assisted living and these medications should be destroyed with the Director of Nursing (DON) or Assistant DON (ADON), but they haven't gotten to it yet. On 2/23/26 at 2:51 PM V2 DON stated when controlled medications are discontinued or the resident expires the nurse should bring the card to the ADON or DON as soon as possible to be destroyed. On 2/25/26 at 10:20 AM V2 stated R9 had an active order for Diazepam that the pharmacy sent a script for on 1/30/26, the order just wasn't placed into R9's electronic medical record and MAR. V2 confirmed the controlled medication entries on the count sheet should match the MAR. On 2/25/26 at 10:39 AM V31 stated R9 always called for Diazepam after 9:00 PM and V31 must have given the medication out of habit without checking to verify it was on the MAR. V31 stated that is my mistake, I should have checked the MAR. 2.) R7's Controlled Substance Record for Lorazepam 0.5 mg documents on 2/9/26 the remaining 13 tablets were destroyed by V10 LPN. R7's Controlled Substance Record for Norco 5/325 mg documents on 2/9/26 the remaining 9 tablets were destroyed by V10.
The Narcotics Destruction Form dated 2/9/26 documents V10 destroyed R7's Lorazepam and Norco tablets and R15's Norco 5/325 mg 60 tablets, 15.5 milliliters (ml) of Morphine Sulfate 100 mg/5 milliliters (ml), 20 ml of Lorazepam concentrate 2 mg/ml, and 10 Fentanyl 25 microgram/hour patches.
These forms are not signed by a second person who witnessed the destruction of these medications.On 2/23/26 at 2:51 PM V2 DON stated controlled medications are destroyed with a floor nurse and either the DON or ADON, with two signatures documented on the destruction form. On 2/25/26 at 9:20 AM V10 reviewed the controlled medication forms dated 2/9/26 and confirmed V10 is the only signature listed for the destruction of R7's and R15's listed medications. V10 stated V10 destroyed the medications with V3 ADON but V3 must have forgot to sign the form. On 2/25/26 at 9:48 AM V3 stated V3 destroyed the controlled medications on 2/9/26 with V10, but V3 forgot to sign the destruction forms.
145480 02/25/2026
Mattoon Rehab & Hcc 2121 South Ninth Mattoon, IL 61938
V2 stated alcohol-based hand sanitizer can be used when hands are not visibly soiled otherwise