Health inspection·September 5, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure dignity was provided during incontinence care and mealtime for five of five residents (R3, R4, R5, R6, R7) reviewed for dignity in a sample list of seven residents.Findings include:1.R3's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Osteoarthritis, Hypertension, Disorders of Bone Density and Structure, Cardiomyopathy, Dysphagia and Mild Protein-Calorie Malnutrition.R3's Brief Interview for Mental Status (BIMS) dated 8/22/25 documents R3 as severely cognitively impaired. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is fully dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 9/4/25 at 1:05 PM V9 and V12 (Certified Nursing Assistants/CNAs) provided incontinence care for R3. V9 and V12 pulled R3's sweatshirt up to R3's chest. V9 and V12 pulled down R3's pants to her knees. V9 removed R3's incontinence brief and provided incontinence care for R3. R3's privacy curtain was pushed back to the wall leaving R3's front and back perineal area entirely exposed during cares provided. R4 (R3's roommate) was sitting in her wheelchair in R3's room during the entire time V9 and V12 were providing incontinence care for R3. On 9/4/25 at 1:20 PM V9 (CNA) stated R3's privacy curtain should have been pulled while providing incontinence care for R3. V9 stated R3 requires total care and is unable to provide privacy for herself. 2. R4's Brief Interview for Mental Status (BIMS) dated 6/19/25 documents R4 as severely cognitively impaired. R4's Functional Abilities and Goals Review dated 6/17/25 documents R4 requires maximum assistance from staff when eating. R5's Brief Interview for Mental Status (BIMS) dated 3/10/25 documents R5 as severely cognitively impaired. R5's Functional Abilities and Goals Review dated 6/10/25 documents R5 is totally dependent on staff for eating.R6's Brief Interview for Mental Status (BIMS) dated 6/27/25 documents R6 as cognitively intact. R6's Functional Abilities and Goals Review dated 6/30/25 documents R6 requires supervision when eating. R7's Brief Interview for Mental Status (BIMS) dated 3/27/25 documents R7 as severely cognitively impaired. R7's Functional Abilities and Goals Review dated 6/24/25 documents R7 is totally dependent on staff for assistance with eating. On 9/5/25 from 7:30 AM-7:50 AM R3, R4, R5, R6 and R7 were sitting at the same dining room table. R6 was feeding herself oatmeal. R6 had oatmeal on her Left cheek and chin. R3, R4, R5 and R7's plates of food were uncovered. The main resident dining room was full of residents eating their breakfast. No staff were present in the dining room.On 9/5/25 at 7:51 AM V10 (CNA) stated two other CNAs did not show up to work today which leaves two CNAs for the front two halls. V10 stated the residents need help eating. V10 walked back and forth from R3, R4, R5 and R7 offering each resident a bite and then moving to the next resident. V10 assisted each resident from a standing position. V10 did not sit with each resident individually. On 9/5/25 at 2:05 PM V2 (Director of Nurses) stated residents should be provided dignity while providing cares for all residents regardless of their cognitive capacity. V2 stated the staff should have pulled R3's Page 1 of 3 145584 145584 09/05/2025 Palm Garden of Mattoon 1000 Palm Mattoon, IL 61938

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some curtain before exposing R3's perineal area when providing cares. V2 stated neither R3 nor R4 are cognitively intact but would expect that neither resident would want to be exposed in front of anyone unnecessarily. V2 stated if there are employee call ins, then ancillary staff are supposed to ‘pitch in' and help the residents until the temporary staffing issue is resolved. V2 stated each resident is supposed to be assisted individually. The facility policy title Dignity revised February 2021 documents each resident shall be cared for in a manner that promotes or enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are to be treated with dignity and respect at all times. 145584 Page 2 of 3 145584 09/05/2025 Palm Garden of Mattoon 1000 Palm Mattoon, IL 61938

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide timely and complete incontinence care for one (R3) dependent resident out of three residents reviewed for incontinence care in a sample list of seven residents.Findings include: R3's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Osteoarthritis, Hypertension, Disorders of Bone Density and Structure, Cardiomyopathy, Dysphagia and Mild Protein-Calorie Malnutrition.R3's Brief Interview for Mental Status (BIMS) dated 8/22/25 documents R3 as severely cognitively impaired. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is fully dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 9/4/25 at 1:00 PM V9 and V12 Certified Nursing Assistants/CNAs) provided incontinence care for R3. V9 and V12 did not provide a clean field for cleansing supplies. V9 placed a white bath towel on R3's personal soft shag pillow sitting on R3's bedside dresser. V9 then opened up R3's incontinence brief and placed it on top of the white towel. V9 then took the towel to the bathroom to wet it down in the sink which left R3's open incontinence brief lying face down directly on top of R3's personal shag pillow. V9 did not cleanse R3's front perineal area. R3's incontinence brief was fully saturated with urine and feces. R3 had a few small pieces of dried feces on her right buttock. On 9/4/25 at 1:18 PM V9 (CNA) stated V9 should have washed R3's front perineal area when providing incontinence care. V9 stated she had not provided incontinence care for R3 since V9 arrived at 6:00 AM. On 9/4/25 at 1:30 PM V11 (CNA) stated she provided incontinence care for R3 at 10:00 AM without the assistance of other staff. On 9/5/25 at 2:00 PM V2 (Director of Nurses) stated staff should provide complete incontinence care for all dependent residents. V2 stated R3 is vulnerable for skin breakdown due to R3 has very low cognition. V2 stated the staff should follow the care plan when providing any cares for residents. V2 stated complete care involves washing the resident's front perineal area first and then moving to the resident's perianal area. The facility policy titled Perineal Cleansing reviewed December 2017 documents staff are to position resident for incontinence care. Place half of the towel underneath the buttocks with the remaining half to be used for covering and drying the perineum. Wash the pubic area including the inner aspect of both thighs and frontal portion of perineum. Use long stroke from the most anterior portion to the base of the labia. Follow the same sequence for rinsing. Dry thoroughly. After washing the perineal area, then wash the perianal area. 145584 Page 3 of 3