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] 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
Page 1 of 3
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
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 (R1, R2) reviewed for controlled substance count sheets in the sample of four.
Findings include: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.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:
145584
If continuation sheet
Page 2 of 3
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
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: R2's Medical Diagnoses List dated November 2025 documents R2 is diagnosed with Chronic
Obstructive Pulmonary Disease, Lymphedema, Cellulitis, Congestive Heart Failure, Chronic Ulcers of the
Feet, Bipolar Disorder, and Depression. R2's Minimum Diagnoses Sheet dated 10/6/25 documents R2 is
cognitively intact. R2's Physician Order Sheet documents R2 is prescribed a no added salt, regular diet.
R2's undated Dietary Card documents 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 R2 stated he is tired of not having any food choices. R2 stated the facility provides no
appealing alternatives for residents that do not choose to eat what is on the menu. R2 stated you either
must eat what is on the menu, or you get peanut butter and jelly. R2 stated there is never a substitute for
the side dishes and no one ever offers him alternate food options. 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. 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:
145584
If continuation sheet
Page 3 of 3
