Palm Garden Of Mattoon

wants to be treated respectfully and does not want to be left lying in his own feces.On 1/28/26 at 1:53 PM, V36 (Registered Nurse/RN) stated she was asked to complete a skin assessment on R93 following an allegation of abuse occurring on 1/13/26. V36 stated R93 reported night-shift CNAs grabbed his arms, held him down, and that a CNA's fingernails tore his skin. V36 stated she observed dried blood on R93's left arm. V36 observed a skin tear on the left forearm and, adjacent to it, a crescent-shaped indentation that broke the skin and had blood present. V36 stated the injury appeared consistent with a fingernail.On 1/28/26 at 2:00 PM, V34 (Agency CNA) stated she worked with R93 on the night shift between 1/12/26 and 1/13/26. V34 stated she and another CNA (V35) entered R93's room to provide care and that R93 became upset. V34 stated R93 became combative and admitted she held his wrists down on the bed. V34 stated R93 was so upset that they were unable to complete care and left him soiled until the next shift.On 1/29/26 at 10:11 AM, V2 (Director of Nursing) stated staff should never antagonize a resident or restrain a resident by holding their arms. V2 stated R93 is typically very cooperative with staff and does not become upset when treated respectfully. V2 confirmed R93 is not known to make false allegations. V2 confirmed R93 alleged emotional and physical abuse and stated staff should never treat a resident in that manner.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

to the cabinet where smoking materials were kept. V16 stated on one occasion R74 spider monkeyed (climbed) over the nurses' station counter to access the cabinet. V16 stated the cabinet had not historically been locked because access behind the nurses' station was controlled by a locked doorway; however, some agency nurses left the door unlocked, allowing R74 access to the cabinet. V16 stated locking the cabinet was a new intervention implemented to prevent R74 from taking vape cartridges. V16 stated vape cartridges were missing for periods ranging from eight hours to a couple of days.The facility Abuse Prevention Policy dated 2/2021, provided by V1 (Administrator) documents the facility affirms residents' rights to be free from abuse, including misappropriation of resident property.

The policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to report all allegations of misappropriation of resident's personal property to the state surveying agency.

This failure affects two residents (R74 and R81) out of six reviewed for misappropriation on the sample list of 39.Findings include:On 1/20/26 at 4:05 PM, R74 stated he had picked up smoking materials, including cigarettes and vape cartridges, that did not belong to him. R74 also stated his own cigarettes and vape cartridges had gone missing.R74's Care Plan, initiated on 12/16/25, documents behavioral problems related to misappropriation of property belonging to others (vapes, lighters, and smoking materials).On 1/21/26 at 1:24 PM, V1 (Administrator) stated there had been allegations of R74 taking other residents' cigarettes and vape cartridges. V1 stated she had been told by regional corporate staff that if the facility retrieved the items at the same time they were taken, it was not considered theft. V1 stated she did not report the allegations of misappropriation to the state surveying agency based on the instructions of regional corporate staff. V1 stated she was aware R81 was one of the residents whose vape cartridges were taken by R74.On 1/21/26 at 1:24 PM, V13 (Human Resources Director) confirmed the statements made by V1.On 1/21/26 at 2:41 PM, V14 (Former Facility Certified Nursing Assistant/CNA), stated he had direct knowledge of R74 taking other residents' cigarettes and vape cartridges. V14 stated R74 had been taking these items for over six months. V14 stated he and other staff had reported the misappropriation to the Administrator but were told that if R74 did not smoke all the cigarettes or use the vape cartridges until they were empty, it was not considered theft and did not need to be replaced or reported.On 1/21/26 at 2:53 PM, R81 stated R74 had taken her vape cartridges on at least four occasions. R81 stated she reported the missing items to staff, including V42 (Former CNA), V17 (Psychiatric Rehabilitation Services Assistant), and V16 (CNA). R81 stated her vape cartridges were missing for periods ranging from one day to a couple of days. R81 stated there were no occasions when staff returned her vape cartridges immediately because she turned her vape cartridges in to nursing staff to be supposedly locked in a cabinet; however, when she returned at the next smoking time, the vape cartridges were missing. R81 stated staff always found her vape cartridges in the possession of R74.On 1/22/26 at 10:56 AM, V16 (CNA) stated he had direct knowledge of R74 taking vape cartridges from other residents. V16 stated he and other staff verbally reported the incidents to the Administrator (V1) on multiple occasions and reported one incident via text message. V16 stated on each occasion the vape cartridges were missing for periods ranging from eight hours to a couple of days.On 1/28/26 at 3:30 PM, V27 (Regional Nurse Consultant) provided a single report to the state surveying agency regarding R74 stealing vape cartridges, dated 12/10/25.The facility's Abuse Prevention Policy dated 2/2021, provided by V1 (Administrator) documents that all alleged violations, including misappropriation of resident property, shall be reported to the state surveying agency and investigated according to the facility's established investigative process.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to allow one (R11) resident the opportunity to choose a destination facility in his involuntary discharge process out of three residents reviewed for discharges in a sample list of 39 residents.Findings include: R11's undated Face Sheet documents R11 was admitted to the facility on [DATE].R11's Electronic Medical Record (EMR) documents medical diagnoses of paraplegia, moderate protein-calorie malnutrition, thoracic spinal cord injury (T7-T10), opioid dependence, neuromuscular dysfunction of the bladder, chronic pain, traumatic brain injury, history of urinary tract infection (UTI), neurogenic bowel, and tobacco use.R11's Minimum Data Set (MDS) dated [DATE] documents R11 is cognitively intact.R11's Involuntary discharge date d 12/1/25 documents R11 would be transferred to another facility located in Illinois.On 1/20/26 at 11:30 AM, R11 stated the facility was kicking him out because he had been aggressive toward staff. R11 stated he occasionally yelled at staff because they don't do what they are supposed to do. R11 stated he had spoken with the Ombudsman and V2 (Director of Nursing/DON), regarding his concerns, stating V1 (Administrator) is the devil. R11 stated V1 had not abused him in any way but stated she should not be in charge of anything. R11 stated he lived in Kentucky prior to residing in Illinois and wanted to return to Kentucky. R11 stated the facility did not ask him where he wanted to go and did not offer him any options in Kentucky.On 1/23/26 at 1:30 PM, V1 (Administrator) stated R11 is a paraplegic resident of the facility. V1 stated V11 (Social Service Director/SSD), could no longer deal with R11 after R11 made a comment about a slip and fall to V11 while V11 was walking down the hall. V1 stated R11 had a verbal altercation with R14 on 10/27/25, which had been reviewed by the state surveying agency with no findings. V1 stated R11 was issued an involuntary discharge on [DATE]. V1 stated the facility sent referrals to multiple other facilities, one of which accepted R11. V1 stated the facility informed R11 of the accepting facility, and R11 threw a fit about not being able to choose where he was going and not being able to return to Kentucky.On 1/28/26 at 9:35 AM, V29 (Ombudsman) stated R11 was issued an emergency involuntary discharge on [DATE] by the facility. V29 stated he had spoken with R11 on multiple occasions and was told R11 wanted to return to Kentucky. V29 stated he discussed R11's wishes with V1 (Administrator) and was told, good luck. V29 stated R11 was not allowed to participate in his own discharge, as the facility did not ask R11 where he wanted to go and did not send referrals to facilities in Kentucky.On 1/28/26 at 10:00 AM, V28 (Director of Admissions) stated he assumed responsibility for R11's discharge because V1 (Administrator), and V11 (Social Service Director) no longer wanted to deal with R11. V28 stated R11 was not permitted to suggest facilities where he wanted to be discharged . V28 stated R11 was issued an involuntary discharge with an accepting facility already identified. V28 stated R11 did not choose that facility; rather, the facility independently sent the referral and informed R11 of the acceptance.The facility policy titled Transfer or Discharge, Facility-Initiated, revised October 2022, documents that residents are to be oriented and prepared for an emergent or immediate facility-initiated discharge when a complete discharge planning process is not practicable.

The policy further documents nursing notes must include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.The undated Illinois Long Term Care Ombudsman Program Resident Rights pamphlet documents residents have the right to participate in their own care planning.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide services to maintain or increase a resident's range of motion.

This failure affected one of three residents (R10) reviewed for Range of Motion on the sample list of 39.

Findings include:The facility's Restorative Nursing Services policy dated July 2017 documents residents will receive restorative nursing care as needed to help promote optimal safety and independence.On 1/20/26 at 1:15 PM, R10 stated that although he prefers to remain in bed most of the time, he would like staff assistance with range-of-motion and strengthening exercises to maintain the strength he still has. R10 stated staff do not ask him to participate in any restorative range-of-motion programs.R10's Minimum Data Set (MDS) dated [DATE] documents R10 is cognitively intact.R10's Physician Order Sheet (POS) dated January 2026 documents diagnoses of adult failure to thrive, lack of coordination, reduced mobility, heart failure, chronic obstructive pulmonary disease, and morbid obesity.R10's Care Plan dated 10/7/25 documents R10 has limited physical mobility and requires staff assistance with bed mobility, transfers, hygiene, and dressing.

The Care Plan documents staff are to provide supportive care and gentle range of motion as tolerated.

The Care Plan further documents R10 is on a Restorative Nursing Active Range of Motion Program consisting of bilateral lower-extremity range-of-motion exercises for 10 repetitions, twice daily.R10's Restorative Program documentation from November 2025, December 2025, and January 2026 documents multiple gaps (over 20 entries) with no documentation indicating restorative exercises were attempted or completed, as well as multiple entries documenting R10 as unavailable.On 1/29/26 at 10:11 AM, V2 (Director of Nursing), confirmed R10 is always in his room and consistently available for staff to complete the restorative range-of-motion program.

V2 stated staff can complete the program while R10 remains in bed and should offer the program multiple times per day. V2 stated the facility employs a restorative aide; however, she stated the aide doesn't really do his job, and that the facility census requires more than one restorative aide to provide effective services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

complained of a headache so she was sent to the emergency room. V7 stated R107 had a 'large' bruise on her Sacral area. R107's fall on 1/1/25 could have been prevented with closer supervision due to the staff knew for 'a few days' that R107 was not feeling good and complained of dizziness with standing. V7 stated R107 fell again on 1/8/25 after therapy walked R107 to the dining room but did not leave a wheelchair for her to use. V7 stated R107 was supposed to use a wheelchair at that point and she did not have one to use. V7 stated R107 wanted the wheelchair and would have used it instead of trying to walk. V7 stated R107 was scared to walk alone and would have used the wheelchair. V7 stated R107's fall on 1/8/25 could have been prevented if R107 had a wheelchair accessible. V7 stated R107 wanted to use the wheelchair due to her fear of falling again.

On 1/29/26 at 9:50 AM V18 (Regional Registered Nurse/RN) stated the facility does not have any documentation to show that fall interventions were in place at the time of R107's falls. V18 stated all residents should have a bedside table. V18 stated that it is a standard piece of equipment and does not know why R107 did not have a bedside table in her room. V18 stated staff should have been supervising R107 if they had known she was complaining of being dizzy when standing. V18 stated a wheelchair should have been left with R107 in the dining room so she wouldn't have walked over to another chair. V18 stated the staff should follow the interventions put into place to help reduce a resident's falls.

The facility policy titled Falls-Clinical Protocol revised March 2018 documents After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur.

• R7's Medical Diagnoses list dated January 2026 documents R7 is diagnosed with Chronic Obstructive

Pulmonary Disease, Fractured Left Tibia, Disorder of Muscles, Lack of Coordination, Gait Abnormalities, Muscle Wasting, Phantom Limb Syndrome, and Right Above the Knee Amputation.

R7's Physician Order Sheet dated January 2026 documents a physician order for a left half side rail in the up position while in bed to enhance bed mobility.

Staff should check positioning and functioning of device.

R7's Health Status Note dated 12/17/25 documents R7 was heard yelling from her room.

Staff went in to check on R7 and found her sitting on the floor by her bed.

The left side rail was on the floor beside her. R7 stated she attempted to sit up on the side of the bed, using the side rail, when it fell off the bed frame, causing R7 to fall with it onto the ground.

On 01/22/2026 10:45 AM V15 (Maintenance Director) stated nursing staff often remove or replace side rails on resident's beds and do not secure them to the bed frames properly. V15 stated this is what he believes happened when R7's bed rail came off the frame and caused her to fall. V15 confirmed the bed rail was not properly secured.

On 1/22/26 at 3:00 PM V2 (Director of Nurses) confirmed only maintenance staff are to remove and install bedrails. V2 confirmed the bedrails need to be installed correctly to be safe and not pose a hazard for residents. V2 confirmed when R7 fell from her bed on 12/17/25, her bed rail came off the bed when she attempted to use it. V2 confirmed the bed rail must not have been secured and therefore posed a hazard which resulted in R7 falling onto the floor.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

Provide safe and appropriate respiratory care for a resident when needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one resident's (R88) respiratory mask from potential cross-contamination, and failed to obtain appropriate physician orders for two residents (R9 and R10) to include required pressures for operation.

This failure affects three residents (R9, R10, and R88) out of three reviewed for respiratory equipment on the sample list of 39.Findings include:1. R88's Census Detail printed 1/28/26 and Diagnoses List printed 1/23/26 document R88 was admitted to the facility on [DATE] with medical diagnoses including Acute and Chronic Respiratory Failure with Hypercapnia (elevated carbon dioxide levels), Chronic Congestive Heart Failure, Morbid Obesity with Alveolar Hypoventilation (lungs do not expand enough to fill adequately), Insomnia, and Obstructive Sleep Apnea (stops breathing when asleep).R88's Physician Order Sheet printed 1/23/26 documents R88 is to use the BIPAP ventilator while sleeping, with the inspiratory pressure set at 14 and the expiratory pressure set at 6.On 1/22/26 at 12:49 PM, R88's BIPAP (non-invasive ventilator) mouth mask was observed sitting in direct contact with a small table surface at the foot of R88's bed.

The mouth mask was not inside any type of protective covering.On 1/22/26 at 12:49 PM, R88 stated she requires staff assistance with placing and removing her BIPAP mask.On 1/22/26 at 3:11 PM, V2 (Director of Nursing) observed and confirmed R88's mask was sitting in direct contact with the table surface without protective covering. V2 stated the facility's practice was to place BIPAP masks in a plastic bag. V2 further stated there had previously been a plastic bag in R88's room containing several BIPAP masks and tubing, which was not present at that time. V2 concluded the plastic bag may have been picked up by the respiratory company representative on Tuesday (1/20/26) when a new mask was delivered to R88.2. R9's Diagnoses List printed 1/23/26 documents R9 has medical conditions including Chronic Bronchitis, Asthma, Morbid Obesity, Obstructive Sleep Apnea, and Chronic Congestive Heart Failure.R9's Physician Order Sheet printed 1/23/26 documents R9 has a physician order to wear a BIPAP while sleeping.

This BIPAP order does not include inspiratory or expiratory pressure settings.3. R10's Diagnoses List printed 1/23/26 documents R10 has medical diagnoses including Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia (low oxygen), Acute and Chronic Congestive Heart Failure, Morbid Obesity, Obstructive Sleep Apnea, Pulmonary Hypertension, Tachypnea (rapid breathing rate), and Insomnia.R10's Physician Order Sheet printed 1/23/26 documents R10 has a physician order to wear the BIPAP as tolerated and to maintain IPAP (Inspiratory Positive Airway Pressure); however, no pressure setting is listed in the order. On 1/28/26 at 3:15 PM, V18 (Regional Nurse) stated she would obtain new physician orders specifying BIPAP settings for R9 and R10.The facility's policy titled CPAP/BIPAP (Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure) Support, dated March 2015, documents nursing staff are to review the physician's order to determine the prescribed oxygen concentration and flow, as well as pressure settings, including CPAP, IPAP (Inspiratory Positive Airway Pressure), and EPAP (Expiratory Positive Airway Pressure), for the machine.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

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 obtain informed consent for use of bilateral bed rails.

The facility also failed to safely and securely install bed rails and failed to maintain safe and secure bed rails for one of six residents (R7) reviewed for accident hazards on the sample list of 39.

Findings Include: The facility's Bed Safety and Bed Rails policy dated August 2022 documents that bed rails must be properly installed. To use bed rails, the facility must obtain informed consent.R7's Medical Diagnoses List dated January 2026 documents R7 is diagnosed with Chronic Obstructive Pulmonary Disease, Fractured Left Tibia, Disorder of Muscles, Lack of Coordination, Gait Abnormalities, Muscle Wasting, Phantom Limb Syndrome, and Right Above-the-Knee Amputation.R7's Physician Order Sheet dated January 2026 documents a physician order for a left half side rail in the up position while in bed to enhance bed mobility.

Staff are to check the positioning and functioning of the device.R7's Bed Rail Transfer Bar Consent dated 2/7/25 documents R7 provided consent to use a left half side rail.R7's Health Status Note dated 12/17/25 documents R7 was heard yelling from her room.

Staff entered the room and found R7 sitting on the floor next to her bed.

The left side rail was on the floor beside her. R7 stated she attempted to sit up on the side of the bed using the side rail when it fell off the bed frame, causing R7 to fall to the floor with it.On 1/22/26 at 10:40 AM, R7's bed had both a right and left half side rail present.

The right-side rail was loose and moved significantly from side to side.On 1/22/26 at 10:45 AM, V15 (Maintenance Director) stated nursing staff often remove or replace side rails on residents' beds and do not secure them to the bed frames properly. V15 stated this is what he believed occurred when R7's bed rail came off the frame and caused her fall. V15 confirmed the bed rail was not properly secured. V15 further confirmed R7's bed currently had two bed rails present and that the right-side rail was not secured properly.

The right-side rail was loose and posed a hazard. V15 removed the right-side rail and stated R7 only had a physician order and consent for a left-side bed rail. V15 stated he was unsure who installed the right-side rail, but it should not have been on R7's bed.On 1/22/26 at 3:00 PM, V2 (Director of Nursing) confirmed only maintenance staff are permitted to remove and install bed rails. V2 confirmed bed rails must be installed correctly to ensure safety and prevent hazards to residents. V2 confirmed that when R7 fell from her bed on 12/17/25, the bed rail came off the bed frame when R7 attempted to use it.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Mattoon

1000 Palm Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

During this time, she begins her early morning medication pass and is unable to consistently assist the sole CNA.On 1/29/26 at 10:11 AM, V2 (DON) confirmed staffing levels from 1/24/26 to 1/25/26 were very low due to winter weather conditions. V2 stated she came to the facility Sunday morning to cover the shift and arrived close to 11:00 AM. V2 confirmed V40 was the only nurse in the building from 8:00 AM until nearly 11:00 AM. V2 stated staffing shortages are an ongoing issue. V2 confirmed the facility utilizes multiple agency staff members who frequently call off, resulting in the facility being short-staffed.On 1/29/26 at 11:24 AM, V40 (LPN) stated she worked the day shift on 1/25/26. V40 stated she was the only nurse in the building from 8:00 AM until 11:00 AM, when V2 (DON) arrived. V40 stated she was assigned to the back halls of the building. V40 confirmed that the morning was particularly stressful, as a resident in the front hall experienced a seizure and fell to the floor. V40 stated the facility is often short-staffed, especially on weekends. V40 stated she feels resident care suffers when staffing is inadequate and resident safety is compromised. V40 stated nurses are unable to perform their duties effectively and must rush through tasks when staffing levels are insufficient.

Facility ID: