Palm Garden of Mattoon: Improper Incontinence Care - IL
The September 4 incident at Palm Garden of Mattoon involved a severely cognitively impaired woman who depends entirely on staff for eating, toileting, bathing and personal hygiene. Federal inspectors found the resident had dried feces on her buttock and a brief fully saturated with urine and feces.
The resident, identified only as R3 in inspection records, has dementia, anxiety and other conditions that leave her completely dependent on staff care. Her cognitive assessment from August 22 classified her as severely impaired.
At 1:00 PM on September 4, certified nursing assistants V9 and V12 began providing incontinence care. V9 placed a white bath towel on the resident's personal soft shag pillow, which was sitting on her bedside dresser. She then opened the resident's incontinence brief and placed it on top of the white towel.
When V9 left to wet the towel in the bathroom sink, she left the open, soiled brief lying face down directly on the resident's personal pillow.
The assistants never cleansed the resident's front perineal area, despite finding dried feces on her right buttock and a brief completely saturated with bodily waste.
Eighteen minutes later, when questioned by inspectors, V9 acknowledged she should have washed the resident's front perineal area during incontinence care. She said she had not provided any incontinence care for the resident since arriving for her shift at 6:00 AM.
Another nursing assistant, V11, told inspectors she had provided incontinence care for the same resident at 10:00 AM that day, working alone without assistance from other staff.
The Director of Nurses acknowledged the care failures when interviewed the following day. V2 told inspectors that staff should provide complete incontinence care for all dependent residents, and that the resident was particularly vulnerable to skin breakdown due to her very low cognition.
"The staff should follow the care plan when providing any cares for residents," V2 said. Complete care involves washing the resident's front perineal area first, then moving to the perianal area.
The facility's own policy requires staff to position residents properly for incontinence care and place half of a towel underneath the buttocks, with the remaining half used for covering and drying the perineum. The December 2017 policy specifies that staff should wash the pubic area, including the inner aspect of both thighs and frontal portion of the perineum, using long strokes from the most anterior portion to the base of the labia.
The policy requires the same sequence for rinsing, followed by thorough drying. Only after washing the perineal area should staff wash the perianal area.
None of these steps were followed during the September 4 care.
The violation represents what federal inspectors classified as minimal harm or potential for actual harm, affecting few residents. However, the incident highlights basic hygiene failures for one of the facility's most vulnerable residents.
The resident's medical record documents multiple conditions requiring careful monitoring, including dementia, mood disturbance, osteoarthritis, hypertension, bone density disorders, cardiomyopathy, difficulty swallowing and mild protein-calorie malnutrition.
Her complete dependence on staff for all activities of daily living makes proper incontinence care critical for preventing infections and skin breakdown. The August assessment confirmed she requires total assistance for bed mobility, transfers, toileting and personal hygiene.
The inspection found that basic infection control principles were violated when staff used the resident's personal belongings as a work surface for contaminated materials. Placing soiled incontinence products on personal items creates additional infection risks beyond the incomplete hygiene care.
Federal inspectors reviewed incontinence care practices for seven residents total, finding problems with one resident's care. The facility failed to ensure that dependent residents received timely and complete incontinence care as required by federal nursing home standards.
The September 5 complaint inspection documented these failures just weeks after the resident's cognitive assessment confirmed her severe impairment and total dependence on staff care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of Mattoon from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on September 5, 2025.
Federal inspectors found the resident had dried feces on her buttock and a brief fully saturated with urine and feces.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.