Palm Garden Of Mattoon

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

curtain before exposing Resident R3's perineal area when providing cares. V2 stated neither Resident R3 nor Resident 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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 (Resident R3) dependent resident out of three residents reviewed for incontinence care in a sample list of seven residents.Findings include: Resident 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.Resident R3's Brief

Interview for Mental Status (BIMS) dated 8/22/25 documents Resident R3 as severely cognitively impaired. Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident 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 Resident R3. V9 and V12 did not provide a clean field for cleansing supplies. V9 placed a white bath towel on Resident R3's personal soft shag pillow sitting on Resident R3's bedside dresser. V9 then opened up Resident 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 Resident R3's open incontinence brief lying face down directly on top of Resident R3's personal shag pillow. V9 did not cleanse Resident R3's front perineal area. Resident R3's incontinence brief was fully saturated with urine and feces. Resident 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 Resident R3's front perineal area when providing incontinence care. V9 stated she had not provided incontinence care for Resident R3 since V9 arrived at 6:00 AM. On 9/4/25 at 1:30 PM V11 (CNA) stated she provided incontinence care for Resident 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 Resident R3 is vulnerable for skin breakdown due to Resident 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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If continuation sheet