Health inspection·May 30, 2025

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 Page 1 of 2 145584 145584 05/30/2025 Palm Garden of Mattoon 1000 Palm Mattoon, IL 61938

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. 145584 Page 2 of 2