F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to maintain a clean, homelike environment in four
of the facility's community shower rooms for two residents (R1, R2) out of three residents reviewed for
physical environment in a sample list of three residents.
Findings include:
On 5/30/25 at 8:30 AM V5 (Licensed Practical Nurse/LPN) showed the east end shower on the back side of
the building. This shower room had round vents in the ceiling that had a nickel thick layer of dust all around
all the rings. The tile around the toilet area measuring three tiles deep by seven tiles wide were missing
showing a rough, uneven floor. V5 LPN stated the staff giving showers open the window when it gets too
humid in the shower room. This same shower room had a baseboard heater with the metal cover removed
revealing the internal heating component. This baseboard heater was positioned inches away from the
shower area.
On 5/30/25 at 8:35 AM V4 (Housekeeper) stated the community shower rooms are sometimes a mess. V4
stated there is one shift of housekeeping. The second and third shift rely on nursing staff to clean those
areas. V4 stated many times V4 will walk into a mess in the shower rooms because residents clog the
toilets, and they overflow or there are garbage cans full of soiled briefs that cause an odor.
On 5/30/25 at 8:40 AM V6 and V7 (Certified Nursing Assistants/CNAs) both stated the east end shower on
the locked North (back) unit does overflow at times. V6 stated there is a vent on the ceiling but it hasn't ever
worked. V7 stated there is no way to turn on the vent so staff will open the windows because it gets so
humid in that shower room.
On 5/30/25 at 8:45 AM The facility back west community shower room did not have a functioning ventilation
system. Staff turned on a switch to activate the venting system, but nothing happened. The ventilator
system did not turn on.
On 5/30/25 at 8:45 AM V9 (CNA) showed the shower room on the west end of the North side of the building
(Psychiatric Unit). V9 stated the showers flood, the tiles are missing and the toilets back up onto the floor
sometimes. This shower room was missing floor tile three tiles deep and seven tiles wide around the toilet
area. V9 stated residents use this toilet often.
On 5/30/25 at 8:50 AM V10 (Maintenance Director) stated he was aware of the missing tiles but had
forgotten about them. V10 stated he was out of the floor tiles but would get them ordered. V10 stated
(continued on next page)
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
Page 1 of 2
Event ID:
145584
Printed: 05/15/2026
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
145584
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/30/2025
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the showers did pool water due to very outdated, poor plumbing. V10 stated We (facility) have to snake the
drains on a regular basis. The vents haven't worked in a long time. We have dehumidifiers but it doesn't do
any good if the staff don't know what they are. The residents are constantly clogging the toilets and we have
to unclog them. Sometimes the toilets run over onto the floor. This plumbing is just plain old. V10 stated the
front-end shower room on the west end does have black mold. V10 stated it had been painted over one
time but may need it again.
On 5/30/25 at 9:20 AM the facility front west hall community shower room ceiling had hundreds of small
black dots on the ceiling. This same shower room has a vent on the ceiling but is not functioning.
On 5/30/25 at 10:00 AM the front hall east shower room shows several inches of tile missing around the
sprinkler head. This area is open with no visible end to the inside of the area. V2 (Director of Nursing/DON)
stated the broken tile should be replaced/fixed. V2 stated this hall was closed for renovations and is now
open back up. V2 stated the hall does have residents that use this shower room.
On 5/30/25 at 10:40 AM V1 (Administrator) stated there are mechanical problems with the facility due to its
age and that facility is working towards fixing those issues.
1. R1's Brief Interview for Mental Assessment (BIMS) dated 3/10/25 documents R1 is cognitively intact.
On 5/30/25 at 9:25 AM R1 stated he does require some assistance with bathing. R1 stated the community
shower room on the front west hall did have a mold problem. R1 stated the facility painted over it to try to fix
it but you can still see it. R1 stated he uses this same shower room twice a week every week.
2. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact.
On 5/30/25 at 9:40 AM R2 stated she does not like the shower room on the east end because 'they are
dirty'. R2 stated she has had to shower in a community shower on east end. R2 stated the east end shower
has pooled water up to her ankles. R2 stated the shower rooms are not ventilated and is makes it difficult to
breathe. R2 stated sometimes the staff will open a window but she does not know who would walk by
outside.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145584
If continuation sheet
Page 2 of 2
