Inspection·August 6, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify one (R1) residents court appointed Guardian of changes in medications and laboratory orders out of three residents reviewed for notifications in a sample list of four residents. Findings Include:R1's Electronic Medical Record (EMR) documents R1's primary diagnosis is the medical management of Paranoid Schizophrenia. Other medical diagnoses include Thyrotoxicosis, Noncompliance with medication regimen, Cannabis abuse with Psychotic Disorder with Hallucinations, Major Depressive Disorder, Anxiety and Insomnia.R1's Letters of Office-Guardianship filed 11/18/2024 documents R1 as a 'Disabled Adult' and that V4 has been appointed R1's Court Appointed Guardian. This same letter documents V4 has access to the psychological healthcare providers and the psychiatric healthcare providers of R1, consent to the psychological and psychiatric treatment for the benefit of R1, consent to or withdraw the administration of psychological and psychiatric, psychotropic medications for the benefit of R1, consent to or refuse any treatment on behalf of R1 for any physical, mental, or emotional illness, consent to and facilitate therapy and counseling services for the benefit of R1 and to take all actions and make all decisions necessary or incidental to the specific authority granted above. R1's Physician Order Set (POS) dated August 2025 documents a physician order starting 11/25/24 for Thyroid Stimulating Hormone (TSH), Free T3 and Free T4 to be drawn monthly. This same POS documents a physician order starting 2/19/25 for R1's TSH, Free T3 and Free T4 to be drawn every three months. This same POS physician orders starting 4/7/25 for Ativan 0.5 milligrams (mg) twice daily for Anxiety. R1's Ativan was changed from an as needed basis to a scheduled dose on 4/7/25. R1's Electronic Medical Record (EMR) does not document V4 (R1's) court appointed Guardian as being notified of R1's psychotropic medication changes nor R1's changes in scheduled lab work.On 8/5/25 at 1:50 PM V4 (R1's Court Appointed Guardian) stated V4 has informed the facility shortly after R1's admission to the facility that V4 is the court appointed guardian and needs to be notified of all changes for R1. V4 stated the facility does not notify her of any medication/behavioral changes with R1. V4 stated R1 was diagnosed with Hyperthyroidism and was supposed to be having lab work done every week prior to her admission to the facility which should have continued through R1's stay. V4 stated if a Physician has changed that order, V4 was never made aware. On 8/5/25 at 3:15 PM V12 (Psychiatric Rehabilitation Services Director/PRSD) stated there is no documentation to show that V4 (R1's Court Appointed Guardian) has been notified of R1's psychotropic medication changes and laboratory order results/changes. V12 stated she spoke with V4 on 7/24/25 during R1's care plan. V12 stated V4 reported R1 has not been receiving her psychotropic medications timely. V12 stated she did not have any answers for V4 at that time but could see in R1's Medication Administration Record (MAR) that R1 had missed several doses of her Ativan. V12 stated she let V2 (Director of Nursing/DON) know of V4's concerns since they are considered clinical concerns. On 8/6/25 at 9:30 AM V2 (DON) stated the facility should have notified V4 (R1's Guardian) of any changes in R1's lab orders, lab results and any medication (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 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 08/06/2025 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)