Palm Garden Of Mattoon
Inspection Findings
F-Tag F0695
F 0695 Level of Harm - Minimal harm or potential for actual harm
humidifier bottle is necessary equipment for administering oxygen. This policy further documents to adjust
the oxygen delivery equipment so the proper flow of oxygen is being administered. This policy documents to check the humidifying jar to be sure there is water in the jar and the water level is high enough that the water bubbles as the oxygen flows through. This policy documents nursing staff are to check the water level periodically.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
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
09/24/2025
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-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on observation, interview, and record review, the facility failed to accurately record provided services by documenting incomplete treatments as completed. This failure affects two residents (Resident R4 and Resident R11) out of five reviewed for specialty services and treatments on the sample list of eleven. Findings include: 1) On 9/23/25 at 10:04 AM, Resident R4 was seated in a recliner in his room receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator running at two and one half liters per minute. Resident R4's oxygen humidifier bottle and nasal cannula tubing were both dated 9/1 (2025) to indicate the last time they were changed. Resident R4's oxygen humidifier bottle was completely dry. Resident R4's current Physician Order Sheet dated 9/24/25 documents Resident R4's oxygen humidifier bottle and nasal cannula tubing need to be changed weekly on Sunday nights. Resident R4's Treatment Administration Record for September, printed on 9/24/25, includes nursing staff initials and a checkmark on each of the scheduled dates when Resident R4's oxygen humidifier bottle and nasal cannula tubing was scheduled to be changed, 9/7, 9/14, and 9/21. 2) On 9/24/25 at 1:48 PM Resident R11 was seated in a chair in his room receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator. Resident R11's oxygen humidifier bottle and nasal cannula tubing were not dated to indicate the last time they were changed. Resident R11's current Physician Order Sheet dated 9/24/25 documents Resident R11's oxygen humidifier bottle and nasal cannula tubing need to be changed weekly on Tuesday nights. Resident R11's Treatment Administration Record for September, printed 9/24/25, includes nursing staff initials and checkmarks on each of the dates Resident R11's oxygen humidifier bottle and nasal cannula tubing was scheduled to be changed, 9/2, 9/9, 9/16, and 9/23. On 9/24/25 at 1:35 PM, V2 (Director of Nursing) confirmed the nurses' initials and checkmarks are placed on the record to indicate the humidifier bottle and nasal cannula tubing had been changed in accordance with the physician orders but obviously had not been changed. V2 further stated the nurses' initials were from agency nurses and not facility staff nurses, but she would need to educate all the nurses, including agency nurses, about accurate documentation. V2 confirmed Resident R4's oxygen humidifier bottle would not run dry in two days, nor Resident R11's run down to one eighth of an inch overnight, if they had been changed as documented by the agency nurses. The facility policy Oxygen Administration dated as revised October 2010, provided by V15, Regional Nurse Consultant, documents information that should be recorded in the resident's medical records including the date and time of procedures, the nurses' name and title who performed the procedure, and needs to be documented or recorded in accordance with professional standards of practice. The facility policy Charting and Documentation dated as revised July 2017 documents all treatments and services provided to the resident shall be documented in the resident's medical record. This policy further documents that all documentation will be complete and accurate.
Event ID:
Facility ID:
If continuation sheet
PALM GARDEN OF MATTOON in MATTOON, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MATTOON, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PALM GARDEN OF MATTOON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.