Palm Garden Of Mattoon

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on observation, interview, and record review the facility failed to update a care plan to accurately include transfer/walking status and assistive devices for one of four residents (Resident R2) reviewed for falls in the sample list of four. Findings include:On 10/14/25 at 12:33 PM Resident R2 was lying in bed with her wheeled walker at the bedside. Resident R2 stated Resident R2 fell in the bathroom a few weeks ago by herself with no initial injuries, but the next day Resident R2 was hurting really bad and found to have broken her tailbone. Resident R2 stated now Resident R2 has to use a wheeled walker and has been receiving therapy. Resident R2 stated Resident R2 transfers and walks independently without any staff assistance. Resident R2's 9/22/25 Minimum Data Set (MDS) documents Resident R2 as cognitively intact and Resident R2 transfers/walks with staff supervision or touch assistance. Resident R2's active care plan includes a problem dated as revised 7/26/24, which documents Resident R2 needs staff supervision and/or assistance with activities of daily living and Resident R2 does not use any assistive devices for walking. This care plan includes interventions dated 6/26/25 which document Resident R2 walks independently without a device and needs set-up assist x1 for transfers.

On 10/15/25 at 11:39 AM V8 (Licensed Practical Nurse/LPN) stated Resident R2 transfers/walks independently without staff assistance. V8 confirmed Resident R2 uses a wheeled walker for transfers/walking which was not updated as part of Resident R2's current care plan. V8 stated V8 was unsure when Resident R2 started using the walker and

the therapy staff would be able to provide that information. On 10/15/25 at 12:20 PM V3 (LPN/MDS Coordinator) stated Resident R2 does not need setup assistance for transfers/walking, Resident R2 is independent and only needs supervision from staff in passing. V3 confirmed Resident R2's care plan does not accurately reflect Resident R2's current transfer/ambulation status. V3 stated Resident R2's care plan should document Resident R2's transfer/walking status as independent with supervision, and not setup assist of one. On 10/15/25 at 12:23 PM V10 (Certified Occupational Therapy Assistant) stated Resident R2 started using the wheeled walker on 7/31/25.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

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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

10/15/2025

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

showed a severely comminuted and markedly displaced fracture of the left distal phalanx of the left finger.

The amputation was almost complete with a small bridge of tissue remaining that did not contain any vessel that could sustain reconstruction. Resident R1 also had cognitive challenges and level of unawareness and a known history of removing dressings, therefore trying to do an open reduction internal fixation and leaving pins in place would be detrimental to the function of Resident R1's hand. The decision was made to proceed with amputation of Resident R1's finger at the level of the distal interphalangeal joint. The facility's investigative file for Resident R1's 9/29/25 fall and injury did not include documentation that interventions were developed and implemented to address Resident R1's behaviors of having Resident R1's fingers in Resident R1's mouth. Resident R1's active care plan includes Resident R1's fall on 9/19/25 and Resident R1's fingertip injury, but does not include a problem, goals, and interventions to address Resident R1's behaviors of having Resident R1's fingers in Resident R1's nose or mouth and to prevent further injuries to Resident R1's fingers. On 10/14/25 at 10:25 AM V3 (LPN/MDS Coordinator) stated on 9/29/25 around 4-4:30 PM Resident R1 was sitting on a folding chair in V3's office, Resident R1 stood from the chair, lost his balance, then fell backwards into the chair and down the wall sliding to the floor onto his bottom. V3 stated Resident R1 held up his left hand after the fall, Resident R1's left middle fingertip was just hanging, and Resident R1 must have bit it off when Resident R1 fell. V3 stated V3 believed Resident R1's unsteadiness caused the fall. V3 stated Resident R1 having Resident R1's finger in Resident R1's mouth made the fall a lot worse and the next day Resident R1 had to have the rest of his fingertip amputated by an orthopedic surgeon. V3 stated Resident R1 had no prior history of finger injuries. At 1:45 PM V3 confirmed Resident R1 has a long history of putting Resident R1's fingers

in his mouth. V3 was asked about interventions and care planning for this behavior. V3 stated staff just tell Resident R1 to keep his fingers out of his mouth. V3 confirmed this should be care planned. V3 stated V3 will update Resident R1's care plan to include this behavior and interventions. On 10/14/25 at 1:55 PM V4 (LPN) stated Resident R1 always has his fingers in his mouth, nose, or pants. V4 was asked what interventions are used to address

these behaviors. V4 stated we just try to tell (Resident R1) to stop. V4 was unsure what new interventions were implemented following Resident R1's fall and injury on 9/29/25. On 10/14/25 at 2:52 PM V6 (LPN) stated on 9/29/25 V6 was called to V3's office following Resident R1's fall. V6 stated V6 found Resident R1 sitting on the floor with a straight line cut across Resident R1's finger and fingernail. V6 stated Resident R1 must have had his finger in his mouth when Resident R1 fell causing the injury. V6 stated it is common for Resident R1 to have Resident R1's fingers in his mouth, nose, or pants. V6 was asked about interventions to address this behavior. V6 stated staff frequently tell Resident R1 to stop putting his fingers in his mouth and Resident R1 will comply. V6 was unsure what new interventions were added after Resident R1's fall injury. V6 stated V3 provided some fidget toys to keep Resident R1's hands busy, but this was just initiated today. On 10/15/25 at 11:39 AM V8 (LPN) confirmed V8 completed the investigation of Resident R1's 9/29/25 fall and injury. V8 stated Resident R1 has a long history of putting Resident R1's hands in his mouth despite staff reminding him not to do that.

V8 stated I don't know what we could have put in place to prevent (Resident R1) from injuring his finger like that or to prevent it from happening again. V8 confirmed interventions were not developed/implemented to address Resident R1's history of putting his fingers in his mouth and to prevent any additional injuries. The facility's Accident and Incidents - Investigating and Reporting policy dated July 2017, documents the nurse supervisor or charge nurse will initiate and document an investigation of the accident or incident. This policy documents that the report of incident/accident form should include the circumstances surrounding the incident, corrective actions taken, follow-up information, and any other pertinent information as necessary or required.

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