Skip to main content
Complaint Investigation

Palm Garden Of Mattoon

September 24, 2025 · Mattoon, IL · 1000 Palm
Citations 2
CMS Rating 1/5
Beds 178
Provider ID 145584
Healthcare Facility
Palm Garden Of Mattoon
Mattoon, IL  ·  View full profile →
Inspection Summary

PALM GARDEN OF MATTOON in MATTOON, IL — inspection on September 24, 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.

Advertisement

Inspection Findings

FF0695
Quality of Life and Care Deficiencies
Potential for More Than Minimal 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

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 (R4 and 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, 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. R4's oxygen humidifier bottle and nasal cannula tubing were both dated 9/1 (2025) to indicate the last time they were changed. R4's oxygen humidifier bottle was completely dry. R4's current Physician Order Sheet dated 9/24/25 documents R4's oxygen humidifier bottle and nasal cannula tubing need to be changed weekly on Sunday nights. 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 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 R11 was seated in a chair in his room receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator. R11's oxygen humidifier bottle and nasal cannula tubing were not dated to indicate the last time they were changed. R11's current Physician Order Sheet dated 9/24/25 documents R11's oxygen humidifier bottle and nasal cannula tubing need to be changed weekly on Tuesday nights. R11's Treatment Administration Record for September, printed 9/24/25, includes nursing staff initials and checkmarks on each of the dates 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 R4's oxygen humidifier bottle would not run dry in two days, nor 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.

Facility ID:

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.


More Reports

Advertisement