Inspection·April 25, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few told R5 to go away. R4 stated R5 was not happy with R4 for not talking to R5 but R5 did leave the area. R4 stated the next day (4/22/25) R5 walked up to R4 and R6 after breakfast when R5 began screaming and yelling profanities at R4 with R6 present. R4 stated She (R5) was saying awful things. (R5) called me a b**** (expletive) and told me to 'go f*** (expletive) myself. R4 stated she began crying as R5 continued to yell and scream at R4 in front of R6. R4 stated finally R5 walked away. R4 stated she was very embarrassed because R5 was saying 'awful' things to her in front of R6. R4 stated R5 told R6 that R5 wanted to have sex with R6. R4 stated R6 refused R5's sexual advances. R4 stated her and R6 are good friends and do not need any other close friends coming between her and R6. R4 stated R5 made her feel scared. R4 was crying during the interview. R4 stated Please don't let (R5) come near me again. I am so scared (R5) will hurt me. (R5) told me she would hurt me bad. I believe (R5). (R5) is a lot bigger than me. (R5) could knock me over and hurt me. I am supposed to walk up and down the halls to exercise my hip. I don't walk down (R5's) hall because I am afraid (R5) will see me and beat me up. (R5) is unpredictable and crazy. I don't want (R5) anywhere near me. R4 stated After lunch that day (4/22) (R5) walked up and started yelling at me. Calling me a b**** (expletive) and telling me how bad I am at sex things. Then (R5) swung her whole arm at me. (R5) didn't actually hit me but I was so scared. I just kept yelling 'Get her off of me! Help me! (R5) is trying to kill me!' On 4/23/25 at 10:25 AM V18 (Psychosocial Rehabilitation Assistant/PRSA) stated R4 was crying hysterically after being screamed at by R5. V18 stated he verbally consoled R4 and then later when R4 was still upset about the matter, the staff allowed R4 to call her sister to help console her also. On 4/23/25 at 11:10 AM V21 (PRSA) stated R5 was 'out of control' on 4/22/25 due to the way R5 was treating R4. V21 stated she heard R5 tell R4 to 'Shut the F*** (expletive) up!' and 'I'll beat you're a** (expletive)!'. V21 stated R5 should have been put on a one-to-one observation but was not. V21 stated R5 kept returning to R4 throughout the day to yell at R4. On 4/23/25 at 12:00 PM R4 left the main dining room for the unit and walked towards the resident hallways. R4 walked down to the end of her hallway, turned around and walked back to the center resident commons area. R4 did not walk down the opposite hallway where R5 resides. On 4/23/25 at 12:40 PM R5 stated R5 yelled, screamed, and cursed at R4 because R4 would not talk to her the day before (4/21/25). R5 stated R4 was in a bad mood so R5 called R4 a b**** (expletive). R5 stated she wished R5 would have hit her when R5 swung at R4. R5 stated I would have hit (R4) right to the ground. R5 stated she tried to 'get with' R6 to make R4 mad but R6 didn't want to be with R5 and that made R5 even more mad. R5 stated she 'went after' R4 several times that day and told R4 what a b**** (expletive) R4 is. On 4/23/25 at 1:40 PM V9 (Psychosocial Rehabilitation Director/PRSD) stated on 4/22/25 after breakfast she heard R5 yelling and screaming in the resident commons area. V9 stated she was in her office right next to the resident common area. V9 stated she went out to see what was going on and saw R5 yelling at R4 and R6 as R5 was walking away from R4. V9 stated she heard R5 call R4 a b**** (expletive). V9 stated R5 was so loud it was hurting her ears. V9 stated R5 told V9 that she had to tell off R4 because R4 is racist. V9 stated V9 told R4 that R5 did not mean anything R5 said. V9 stated R4 was crying, tearful and stating she was very scared of R5. V9 stated R6 stated he heard R5 call R4 a b**** (expletive) and to 'get the f*** (expletive) out of R5's way'. V9 stated R4 calmed down after about an hour. V9 stated R5 went back to her room and V9 went back to her office. V9 stated she is the director of the psychiatric locked down unit and was never told that she had to report verbal and/or mental abuse to V1 (Abuse Coordinator/Administrator). V9 stated after lunch R5 walked up to R6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 2 of 7 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 04/25/2025 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 0600 Level of Harm - Actual harm and stated R5 could do R6 'sexual favors' better than R4. V9 stated this made R5 mad so she started yelling at R4 and R6 again. V9 stated R5 called R4 a b**** (expletive). V9 stated V8 (Psychosocial Rehabilitation Counselor/PRSC) then came out to help de-escalate R5. V9 stated R4 was terrified and tearful after being yelled at by R5. Residents Affected - Few On 4/25/25 at 1:00 PM V24 (Nurse Practitioner/NP) stated R5 yelling, screaming derogatory words, and attempting to hit R4 could have a negative effect on R4. V24 stated R4 could experience Post Traumatic Stress Disorder (PTSD), Anxiety and Insomnia caused by R5 verbally and mentally abusing R4. V24 stated R5 humiliated R4 in front of her close friend R6 which could cause R4 to have regressive behaviors. V24 stated mentally ill residents such as R5 do have behaviors but this instance of R5 verbally and mentally abusing R4 would be considered abuse. On 4/25/25 at 2:35 PM V20 (Regional Director of Operations) stated the facility should have communicated better in order to monitor R5 for behaviors. V20 stated the staff were aware R5 was upset with R4 on the day before (4/21/25) R5 abused R4. V20 stated these incidents could possibly have been avoided if the staff were paying closer attention. V20 stated the locked unit houses mentally ill individuals who need extra support and monitoring to prevent these types of things from happening. V20 stated the facility is re-training their staff on the facility Abuse policy and behavior management to reduce abuse. The facility policy titled Abuse Prevention Program revised 11/28/2016 documents the facility affirms the right of our resident to be free from abuse, neglect, misappropriate of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is the willful injection of injury, unreasonable confinement, intimidate, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not lied to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident, harassment, humiliation and threats of punishment or deprivation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 3 of 7 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 04/25/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of verbal and/or mental abuse to the Abuse Coordinator timely on three separate occasions involving R5 verbally and mentally abusing R4 on 4/22/25, R8 verbally abusing R7 on 4/6/25 and R9 verbally abusing R10 on 4/7/25. These failures affect six residents out of nine residents reviewed for abuse in a sample list of 12 residents. Findings include: 1. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R4 and R5's shared Initial Report to the State Agency dated 4/23/25 documents R5 allegedly verbally abused R4 on 4/22/25. On 4/23/25 at 1:45 PM V9 (Psychosocial Rehabilitation Director/PRSD) stated she was aware that R5 had yelled and screamed profanities and took a swing at R4 on 4/22/25 and did not report that behavior to anyone. V9 stated she was not aware that verbal and/or mental abuse needed to be reported as an allegation of abuse. V9 stated R4 reported to V19 (Registered Nurse/RN) the next day (4/23/25) and that is the only reason anything was reported to the State Agency. V9 (PRSD) stated she should have reported the incidents between R4 and R5 to V1 (Administrator/Abuse Coordinator) or V20 (Regional Director of Operations) immediately. 2. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as severely cognitively impaired. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Nurse Progress Note dated 4/6/25 at 12:44 AM documents (R8) had behaviors this evening. (R8) was upset that her roommate (R8) 'disrespected her'. (V22) Agency Licensed Practical Nurse (LPN) entered (R7, R8) room because (V22) heard (R8) yelling at her roommate (R7). (R8) was upset (R7's) radio was too loud. (R8) yelled at nurse also before calming down. R7 and R8's shared initial Report to the State Agency dated 4/25/25 documents R7 and R8 were involved in a resident-to-resident verbal altercation on 4/6/25. On 4/24/25 at 2:25 PM R7 stated her prior roommate (R8) yelled at her. R7 stated R8 called her an 'old deaf b**** (expletive)' because R7 liked to listen to her radio. R7 stated it wasn't nice of R8 to call her names and it hurt her feelings. On 4/24/25 at 2:30 PM R8 stated R8 yelled and cussed at R7 because R7 had her radio too loud. R8 stated R7's radio was so loud it hurt her ears so R8 called R7 a 'deaf b**** (expletive)'. R8 stated R7 started crying after that and a nurse (V22) came in and interrupted R8 yelling at R7. On 4/24/25 at 11:20 AM V9 (Psychosocial Rehabilitation Director/PRSD) stated she was not aware that R8 had yelled at R7 on 4/6/25. V9 stated an agency nurse (V22 Licensed Practical Nurse) documented that R8 had yelled at R7 but V22 did not let anyone know that. V9 stated V22 should have notified V9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 4 of 7 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 04/25/2025 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 0609 and V1 so that incident of verbal abuse could have been reported and investigated. Level of Harm - Minimal harm or potential for actual harm 3. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact. Residents Affected - Some R10's Nurse Progress Note dated 4/7/25 at 3:22 PM documents (R10) also got into a screaming match with (R9) at BINGO causing (R9) to become upset. R9 and R10's shared initial Report to the State Agency dated 4/25/25 documents R9 and R10 were involved in a resident-to-resident verbal altercation on 4/7/25. On 4/24/25 at 11:25 AM V9 (PRSD) stated she remembers the day that R9 and R10 had a screaming match in the dining room during BINGO on 4/7/25. V9 stated R10 yells out 'Help me!' and 'Hug me!' a lot and was yelling out that day. V9 stated R9 was upset by R10's behavior and started yelling at R10 that R10 was a 'stupid b**** (expletive)' and to 'shut the h*** (expletive) up!' V9 stated R10 didn't like being called names and being yelled at by R9 and started crying. V9 stated R9 had to be removed from BINGO due to her verbally abusing R10. V9 stated this incident should have been reported to V1 (Administrator/Abuse Coordinator) but wasn't. V9 stated she did not know that verbal/mental abuse needed to be reported. V9 stated That is just how they (residents) act sometimes. We (staff) remove the bad one from the bunch. They (residents) are like little children who need disciplined or punished for their bad behavior. We (staff) need to make sure they (residents) know there will be consequences to their actions/behaviors. I just did not realize anytime a resident who verbally/mentally abuses another resident had to get so much attention about the incident. I was never told that verbal/mental abuse needed to be reported and investigated. On 4/25/25 at 2:45 PM V20 (Regional Director of Operations) stated all three of these incidents should have been reported to the Abuse Coordinator/designee immediately. V20 stated if R4 would not have told V19 (RN), then V1 (Administrator/Abuse Coordinator) would not have known R5 had abused R4. V20 stated the floor staff, supervisory staff and ancillary staff have all had previous Abuse trainings. V20 stated V1 is also the Abuse Coordinator and has been on vacation. V20 stated the staff have all been trained to follow the chain of command and notify V2 (Director of Nurses) and/or one of the regional staff who have been in the facility when V1 has been gone. V20 stated there really is no excuse for not calling someone to report any type of abuse. V20 stated the facility staff are being trained on the Abuse policy again to try to ensure everyone knows that reporting Abuse should be immediate and is mandatory. The facility policy titled Abuse Prevention Program revised 11/28/2016 documents employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. Supervisors shall immediately inform the Administrator or his/her designated representative of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 5 of 7 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 04/25/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect one (R4) resident from being repeatedly verbally and mentally abused by another resident (R5) throughout an entire day while the staff were aware of R4 being abused. Two residents (R4, R5) were affected by this failure out of nine residents reviewed for abuse in a sample list of 12 residents. R4 felt scared causing her to change her activity routine in fear of being further abused by R5. Residents Affected - Few Findings include: R4's undated Face Sheet documents medical diagnoses as Bipolar Disorder, Anxiety, Non-Rheumatic Mitral and Pulmonary Valve Insufficiency, Chronic Diastolic Congestive Heart Failure, Syncope and Collapse. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 requires supervision with dressing, bathing, personal hygiene, bed mobility and transfers. R4's Initial Report to the State Agency documents R5 allegedly verbally abused R4 on 4/22/25. R4's initial Abuse Investigation dated 4/23/25 documents R5 told R4 to 'stay away from my man you b**** (expletive)' and then R5 swung at R4. This same investigation documents R4 was sitting with R6 when R5 said R5 wanted to go to bed with R6. This same file documents R4 was walking down the hall after supper and R5 said 'stay away from me b**** (expletive)'. On 4/23/25 at 12:00 PM R4 left the main dining room for the unit and walked towards the resident hallways. R4 walked down to the end of her hallway, turned around and walked back to the center resident commons area. R4 did not walk down the opposite hallway where R5 resides. R5 left the dining room a few minutes later, stopped in the same commons area, looked towards R4, and then proceeded to her own room. No staff were present in the dining room nor in the commons area. On 4/24/25 at 12:10 PM R4 and R5 were sitting in the dining room at the same time during lunch service. R5 stood and walked by R4. There were no staff in the dining room at that time. On 4/23/25 at 9:45 AM R4 stated R5 yelled and screamed 'foul' language at her multiple times on 4/22/25. R4 stated R5 swung at her at one point. R4 stated the staff, including V9 (Psychosocial Rehabilitation Director/PRSD) was aware that R5 kept walking up to R4 to yell obscenities at R4. R4 stated R5 made her feel scared. R4 was crying during the interview. R4 stated Please don't let (R5) come near me again. I am so scared (R5) will hurt me. (R5) told me she would hurt me bad. I believe (R5). (R5) is a lot bigger than me. (R5) could knock me over and hurt me. I don't walk down (R5's) hall because I am afraid (R5) will see me and beat me up. I don't want (R5) anywhere near me. R4 stated R5 walked up to R4 'multiple' times on 4/22/25, yelling profanities and threatening to hurt R4. R4 stated After lunch that day (4/22) (R5) walked up and started yelling at me. Calling me a b**** (expletive) and telling me how bad I am at sex things. Then (R5) swung her whole arm at me. (R5) didn't actually hit me but I was so scared!' R4 stated V8 (Psychosocial Rehabilitation Counselor/PRSC) and V9 (PRSD) were aware of R5's behaviors on 4/22/25. R4 stated the facility did not do anything to help R4 so she told V19 (Registered Nurse/RN) the next morning (4/23/25). R4 stated she did not sleep the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 6 of 7 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 04/25/2025 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 0610 Level of Harm - Actual harm night of 4/22/25 for fear R5 would come into her room and attack her. R4 stated R5 lived right across the hall from her at that time so R5 could easily walk over into R4's room to hurt her. R4 stated I know (V19) Registered Nurse (RN) would help me, so I waited for her to come into work the next morning (4/23/25) and told her what happened. Residents Affected - Few On 4/23/25 at 11:10 AM V21 (Psychosocial Rehabilitation Assistant/PRSA) stated R5 was 'out of control' on 4/22/25 due to the way R5 was treating R4. V21 stated she heard R5 tell R4 to 'Shut the F*** (expletive) up!' and 'I'll beat you're a** (expletive)!'. V21 stated R5 should have been put on a one-to-one observation but was not. V21 stated R5 kept returning to R4 throughout the day to yell at R4. On 4/23/25 at 12:40 PM R5 stated she wished R5 would have hit her when R5 swung at R4. R5 stated I would have hit (R4) right to the ground. R5 stated she 'went after' R4 several times that day and told R4 what a b**** (expletive) R4 is. On 4/23/25 at 1:40 PM V9 (PRSD) stated V9 was aware that R5 walked up to R4 multiple times throughout the day (4/22/25) to yell and scream profanities at R4 due to R4 did not talk to R5 the day before (4/21/25). V9 stated she should have separated R5 from everyone until they (staff) could figure out what had happened and to ensure the safety of R4. V9 stated R4 could have been hurt. V9 stated R5 did threaten to hurt R4 and 'you never know if a threat is real or not until something happens'. V9 stated R5 was placed on 15-minute checks on 4/23/25 at 11:00 AM. V9 stated R5 should have been placed on a one-to-one continuous observations due to her repeatedly abusing R4. On 4/25/25 at 1:10 PM V24 (Nurse Practitioner/NP) stated R5 should have been sent to the emergency room for a psychiatric evaluation by a physician. V24 stated R5 isn't known to have those kinds of behaviors. V24 stated R5 could have had some clinical issue happening or R5 could have been going through some type of new mental health issue that she had not experienced before. V24 stated R4 was not protected by this facility due to R5 was not monitored closely enough if R5 was allowed to repeatedly abuse R4 verbally and mentally. On 4/25/25 at 2:30 PM V20 (Regional Director of Operations) stated the staff should have monitored R5 more closely after they were aware that R5 had yelled at R4 after breakfast on 4/22/25. V20 stated R4 was not protected from R5's repeated abuse and should have been. The facility policy titled Abuse Prevention Program revised 11/28/2016 documents residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145584 If continuation sheet Page 7 of 7