Palm Garden Of Mattoon
PALM GARDEN OF MATTOON in MATTOON, IL — inspection on September 5, 2025.
Found 2 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
curtain before exposing R3's perineal area when providing cares. V2 stated neither R3 nor R4 are cognitively intact but would expect that neither resident would want to be exposed in front of anyone unnecessarily. V2 stated if there are employee call ins, then ancillary staff are supposed to ‘pitch in' and help the residents until the temporary staffing issue is resolved. V2 stated each resident is supposed to be assisted individually.
The facility policy title Dignity revised February 2021 documents each resident shall be cared for in a manner that promotes or enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem.
Residents are to be treated with dignity and respect at all times.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Mattoon
1000 Palm Mattoon, IL 61938
SUMMARY STATEMENT OF DEFICIENCIES
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 provide timely and complete incontinence care for one (R3) dependent resident out of three residents reviewed for incontinence care in a sample list of seven residents.Findings include: R3's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Osteoarthritis, Hypertension, Disorders of Bone Density and Structure, Cardiomyopathy, Dysphagia and Mild Protein-Calorie Malnutrition.R3's Brief Interview for Mental Status (BIMS) dated 8/22/25 documents R3 as severely cognitively impaired. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is fully dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 9/4/25 at 1:00 PM V9 and V12 Certified Nursing Assistants/CNAs) provided incontinence care for R3. V9 and V12 did not provide a clean field for cleansing supplies. V9 placed a white bath towel on R3's personal soft shag pillow sitting on R3's bedside dresser. V9 then opened up R3's incontinence brief and placed it on top of the white towel. V9 then took the towel to the bathroom to wet it down in the sink which left R3's open incontinence brief lying face down directly on top of R3's personal shag pillow. V9 did not cleanse R3's front perineal area. R3's incontinence brief was fully saturated with urine and feces. R3 had a few small pieces of dried feces on her right buttock. On 9/4/25 at 1:18 PM V9 (CNA) stated V9 should have washed R3's front perineal area when providing incontinence care. V9 stated she had not provided incontinence care for R3 since V9 arrived at 6:00 AM. On 9/4/25 at 1:30 PM V11 (CNA) stated she provided incontinence care for R3 at 10:00 AM without the assistance of other staff. On 9/5/25 at 2:00 PM V2 (Director of Nurses) stated staff should provide complete incontinence care for all dependent residents. V2 stated R3 is vulnerable for skin breakdown due to R3 has very low cognition. V2 stated the staff should follow the care plan when providing any cares for residents. V2 stated complete care involves washing the resident's front perineal area first and then moving to the resident's perianal area.
The facility policy titled Perineal Cleansing reviewed December 2017 documents staff are to position resident for incontinence care.
Place half of the towel underneath the buttocks with the remaining half to be used for covering and drying the perineum.
Wash the pubic area including the inner aspect of both thighs and frontal portion of perineum.
Use long stroke from the most anterior portion to the base of the labia.
Follow the same sequence for rinsing.
Dry thoroughly.
After washing the perineal area, then wash the perianal area.
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