Palm Garden Of Mattoon

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 98 residents in the facility.Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/25 through 11/28/25 documented seven days (11/1, 11/2, 11/8, 11/9, 11/15, 11/22, 11/23) that the facility failed to use

the services of a Registered Nurse for at least eight consecutive hours. On 11/28/25 at 2:34 PM V2 (Director of Nurses) confirmed the facility did not have eight hours of Registered Nurse coverage every day, especially on the weekends when administration staff aren't at the facility to cover. V2 also confirmed the facility's current census was 98 residents. The facility's Facility assessment dated [DATE REDACTED] documents a Registered Nurse is needed every day in order to provide competent support and care for the facility's resident population.

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

Facility ID:

If continuation sheet

Event ID:

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

11/30/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview and record review, the facility failed to ensure the nursing staff consistently completed and signed controlled substance count sheets at the end of each shift. This failure has the potential to affect two of four residents (Resident R1, Resident R2) reviewed for controlled substance count sheets in the sample of four.

Findings include:Resident R1's Physician Order Sheet dated November 2025 documents an order for HydrocodoneAcetaminophen (Opioid combination-controlled substance) 10-325 milligrams every four hours as needed for pain.Resident R2's Physician Order Sheet dated November 2025 documents an order for HydrocodoneAcetaminophen (Opioid combination-controlled substance) 5-325 milligrams for arthritis pain.Review of the facility's Shift Verification of Controlled Substances Count sheets dated August 2025, September 2025, October 2025, and November 2025, document numerous blanks where nurses did not sign off as performing the count for multiple shifts during these four months.On 11/28/25 at 10:00 AM, V4 (Licensed Practical Nurse/LPN) stated the count is done after very shift but V4 forgot to do it today.On 11/28/25 at 2:12 PM, V2 (Director of Nursing/DON) stated the controlled substance count should be completed at the beginning and end of each shift.The facility's Controlled Substances Policy dated November 2022, documents nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. This policy also documents the nurse coming on duty and the nurse going off duty make the count together.

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

11/30/2025

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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Based on observation, interview and record review the facility failed to provide food that accommodates resident preferences and failed to provide appealing options to residents who choose not to eat food that is initially served. These failures have the potential to affect all 98 residents residing in the facility. Findings Include: Resident R2's Medical Diagnoses List dated November 2025 documents Resident R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Lymphedema, Cellulitis, Congestive Heart Failure, Chronic Ulcers of the Feet, Bipolar Disorder, and Depression. Resident R2's Minimum Diagnoses Sheet dated 10/6/25 documents Resident R2 is cognitively intact. Resident R2's Physician Order Sheet documents Resident R2 is prescribed a no added salt, regular diet. Resident R2's undated Dietary Card documents Resident R2 dislikes fish, chicken, beets, or squash. The facility's Monthly Menus dated 11/23/25 documents chicken or fish will be served 13 times throughout the month. On 11/30/25 at 1:20 PM Resident R2 stated he is tired of not having any food choices. Resident R2 stated the facility provides no appealing alternatives for residents that do not choose to eat what is on the menu. Resident R2 stated you either must eat what is on the menu, or you get peanut butter and jelly. Resident R2 stated there is never a substitute for

the side dishes and no one ever offers him alternate food options. Resident R2 stated he sees people go without eating because they don't like what's on the menu and there aren't other choices available. Resident R2 stated his tray card states he does not like chicken or fish however the staff still serve him chicken or fish if it is on the menu because there is no other option. On 11/28/25 at 1:52 PM V11 (Cook) confirmed the facility has one meal on the menu and no alternative. V11 stated the cook on duty usually checks the fridge to see if there are any leftovers or makes peanut butter and jelly sandwiches for the residents that don't choose to eat what is on the menu. V11 stated the kitchen does not have alternatives for the vegetables or fruit on the menu. V11 confirmed residents don't have much of a choice when it comes to meals. Either they eat what is served, or they have to eat a peanut butter jelly sandwich or the random leftover. V11 stated it would be nice to have an always available menu or more options for the residents to choose from.On 11/28/25 at 2:34 PM V2 (Director of Nurses) stated she believes the facility should be honoring resident preferences and providing them a choice of food options if they don't choose to eat what is on the menu that meal. V2 confirmed the current daily census is 98 residents.

Event ID:

Facility ID:

If continuation sheet