Palm Garden Of Mattoon
PALM GARDEN OF MATTOON in MATTOON, IL — inspection on October 15, 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
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 (R2) reviewed for falls in the sample list of four.
Findings include:On 10/14/25 at 12:33 PM R2 was lying in bed with her wheeled walker at the bedside. R2 stated R2 fell in the bathroom a few weeks ago by herself with no initial injuries, but the next day R2 was hurting really bad and found to have broken her tailbone. R2 stated now R2 has to use a wheeled walker and has been receiving therapy. R2 stated R2 transfers and walks independently without any staff assistance. R2's 9/22/25 Minimum Data Set (MDS) documents R2 as cognitively intact and R2 transfers/walks with staff supervision or touch assistance. R2's active care plan includes a problem dated as revised 7/26/24, which documents R2 needs staff supervision and/or assistance with activities of daily living and R2 does not use any assistive devices for walking.
This care plan includes interventions dated 6/26/25 which document 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 R2 transfers/walks independently without staff assistance. V8 confirmed R2 uses a wheeled walker for transfers/walking which was not updated as part of R2's current care plan. V8 stated V8 was unsure when 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 R2 does not need setup assistance for transfers/walking, R2 is independent and only needs supervision from staff in passing. V3 confirmed R2's care plan does not accurately reflect R2's current transfer/ambulation status. V3 stated R2's care plan should document 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 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Mattoon
1000 Palm Mattoon, IL 61938
SUMMARY STATEMENT OF DEFICIENCIES
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. 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 R1's hand.
The decision was made to proceed with amputation of R1's finger at the level of the distal interphalangeal joint.
The facility's investigative file for R1's 9/29/25 fall and injury did not include documentation that interventions were developed and implemented to address R1's behaviors of having R1's fingers in R1's mouth. R1's active care plan includes R1's fall on 9/19/25 and R1's fingertip injury, but does not include a problem, goals, and interventions to address R1's behaviors of having R1's fingers in R1's nose or mouth and to prevent further injuries to 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 R1 was sitting on a folding chair in V3's office, 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 R1 held up his left hand after the fall, R1's left middle fingertip was just hanging, and R1 must have bit it off when R1 fell. V3 stated V3 believed R1's unsteadiness caused the fall. V3 stated R1 having R1's finger in R1's mouth made the fall a lot worse and the next day R1 had to have the rest of his fingertip amputated by an orthopedic surgeon. V3 stated R1 had no prior history of finger injuries. At 1:45 PM V3 confirmed R1 has a long history of putting R1's fingers in his mouth. V3 was asked about interventions and care planning for this behavior. V3 stated staff just tell R1 to keep his fingers out of his mouth. V3 confirmed this should be care planned. V3 stated V3 will update R1's care plan to include this behavior and interventions. On 10/14/25 at 1:55 PM V4 (LPN) stated 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 (R1) to stop. V4 was unsure what new interventions were implemented following 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 R1's fall. V6 stated V6 found R1 sitting on the floor with a straight line cut across R1's finger and fingernail. V6 stated R1 must have had his finger in his mouth when R1 fell causing the injury. V6 stated it is common for R1 to have R1's fingers in his mouth, nose, or pants. V6 was asked about interventions to address this behavior. V6 stated staff frequently tell R1 to stop putting his fingers in his mouth and R1 will comply. V6 was unsure what new interventions were added after R1's fall injury. V6 stated V3 provided some fidget toys to keep 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 R1's 9/29/25 fall and injury. V8 stated R1 has a long history of putting 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 (R1) from injuring his finger like that or to prevent it from happening again. V8 confirmed interventions were not developed/implemented to address 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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