Inspection·April 19, 2025

F 0725 answered R2's call light. Level of Harm - Minimal harm or potential for actual harm On 4/19/25 at 10:00 AM R2 was sitting in his recliner in his room. R2 was sitting on a mechanical lift sling. R2 stated he turned on his call light early that morning to be changed and get up. R2 stated his call light went off for over 30 minutes before someone came in and then was told there aren't enough staff to get R2 up and he would have to wait until day shift staff arrived. R2 stated he did not think that was right. R2 stated he understands the staff are busy but in case of an emergency, R2 would be one of the last residents helped due to his increased need for help with transfers and the lack of staff to help him. Residents Affected - Many 2. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. On 4/19/25 at 9:40 AM R1 stated the facility needs more staff. R1 stated there is one nurse for both the 500 and 600 halls at night and sometimes only one CNA. R1 stated he had his call light on for an hour earlier this morning (4/19/25) before someone answered it. R1 stated I can't get up on my own because of my legs being so swollen (pointing to his bilateral legs which were wrapped with compression gauze). Someone is going to get hurt, and no one would even know about it. We (residents) are not cattle. I deserve better than that. 3. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 4/19/25 at 9:10 AM R4 stated R4 is the President of Resident Council for the 'front' half of the building (100 hall). R4 stated the staff are helpful when they get to you. R4 stated it is not uncommon for her to have to wait for 30-45 minutes to have her call light answered due to lack of staffing. R4 stated When they (facility) only put one CNA on our hall with 25-30 people somebody, or should I say a lot of somebodies are going to have to wait. If they had an emergency, we would all perish. 4. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact. On 4/19/25 at 9:15 AM R5 stated the staff are helpful but she does have to wait sometimes up to an hour for her call light to be answered because there are not enough staff. R5 stated she does not like waiting for help that long. R5 stated There (pointing to a commode with no lid exposing yellow urine) is a perfect example. I asked one of the CNAs to empty that thing before breakfast and she said she would when she got done helping other people. I had turned on my light and had to wait 40 minutes to be told to wait. I understand they (staff) are busy but now I have to sit here and smell urine. This place needs more help. On 4/19/25 at 5:10 AM V6 (Agency Licensed Practical Nurse/LPN) stated her halls (500, 600) are very short tonight due to a CNA going home at 2:00 AM and no one came in to replace that person. V6 stated there have been call lights going off and not enough help to answer them. V6 stated residents do have to wait to get their needs met. V6 stated V6 has the choice to help the residents with their cares or pass their medications and do their treatments. On 4/19/25 at 11:00 AM V9 (Scheduler) stated the facility has been struggling to find CNAs to cover all the shifts. V9 stated the facility does use agency CNAs to help alleviate some of the open shifts. V9 stated the facility has been allowing flexible scheduling with their current CNAs to cover some of the busier times such as getting residents up for the day or putting them to bed. V9 stated the Daily 24-Hour Staffing sheets are complete and any adjustments have already been made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 2 of 4 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 04/19/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 4/19/25 at 12:00 PM V3 (Regional Director of Operations) reviewed the daily staffing sheets. V3 reviewed the staffing timeclock ins/outs to see if there were any adjustments that were not showing on the daily staffing sheets. V3 stated the days listed above 4/5, 4/6, 4/12, 4/13, 4/14, 4/16, 4/17 and 4/18 were all lacking the required CNA staffing to care for the facility's resident population. V3 stated the staff present in the facility are doing the best they can but the facility is also trying to hire more staff to alleviate the staffing shortage. The undated facility policy titled Nurse Staffing documents it is the policy of the facility to licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and/or psychosocial well-being of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 3 of 4 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 04/19/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a medication error rate under five percent for one (R3) resident out of four residents reviewed for medications in a sample list of seven residents. A medication administration pass was completed with three errors out of 28 opportunities resulting in a 10.7% medication error rate. Residents Affected - Few Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. R3's Physician Order Sheet (POS) dated April 2025 documents a physician order for Calgest (TUMS) 500 milligrams (mg) two chewable tablets twice a day, Gabapentin 300 mg three times a day, Levetiracetam 500 milligrams (mg) three tablets orally twice a day and Calcium 600 mg + (plus) D3 200 mg tablet daily. On 4/19/25 at 6:25 AM R3's Gabapentin medication card had a sticker that documents No Alum/Mag (Aluminum/Magnesium) Antacid within two hours. V8 (Licensed Practical Nurse/LPN) administered Calgest (TUMS) 500 mg two tablets and Gabapentin 300 mg together. V8 also administered Levetiracetam 500 mg one tablet to R3. V8 LPN did not administer Calcium 600 mg + (plus) D3 200 mg tablet. R3's Calgest ingredient list include Calcium Carbonate and Magnesium Stearate. On 4/19/25 at 10:05 AM V8 (LPN) stated she did not read R2's Gabapentin label that instructed to not give Gabapentin and TUMS within two hours of each other. V8 stated she knew R3 should receive three tablets of Levetiracetam but got in a hurry and did not give the other two tablets. V8 stated she did not give R2's Calcium 600 mg + D3 200 mg tablet because it has not come in yet. V8 LPN stated R3's Calcium 600 mg + D3 200 mg was ordered from the pharmacy but has never come in yet. The facility policy titled Medication Administration revised 11/18/2017 documents the complete act of medication administration entails verifying the medication with the physician orders. When preparing medication for administration, check the label of the drug container a minimum of three times for safety and accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 4 of 4