Inspection·September 24, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to obtain physician orders for oxygen therapy (R4), failed to administer oxygen according to physician orders (R11), and failed to change oxygen humidifier bottles and tubing according to physician orders (R4 and R11). These failures affect two residents (R4 and R11) out of five reviewed for specialized services on a sample of eleven. Findings include: 1) R4's medical diagnoses list dated 9/24/25 documents R4 experiences medical conditions including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Respiratory Conditions due to Unspecified External Agent, Chronic Congestive Heart Failure, and Unstable Chest Pain. On 9/23/25 at 10:04 AM, R4 was seated in a recliner in his room receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator running at two and one half liters per minute. R4's oxygen humidifier bottle was completely dry. R4's nasal cannula and humidifier bottle were dated 9/1 (2025). On 9/23/25 at 10:04 AM, R4 stated his oxygen should be running around 4 liters per minute. R4 acknowledged his oxygen humidifier bottle was dry and stated it happens frequently. On 9/24/25 at 1:25 PM, R4 was seated in a recliner in his room, again receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator running at two and one half liters per minute. R4 stated no one had come to give him a new oxygen humidifier bottle yet. R4's current physician order sheet dated 9/24/25 did not include any physician orders for oxygen therapy, the rate at which R4 was to receive oxygen, nor the delivery method such as from a mask versus the nasal cannula tubing. This same physician order sheet did document R4's oxygen humidifier bottle and nasal cannula tubing were to be changed weekly every Sunday night. On 9/24/25 at 1:35 PM, V2 (Director of Nursing) stated R4's oxygen humidifier bottle and nasal cannula tubing were supposed to be changed every Sunday night. 2) R11's medical diagnoses list dated 9/24/25 documents R11 experiences medical conditions including Emphysema, Sleep Apnea, and Solitary Pulmonary Nodule. On 9/24/25 at 1:48 PM, R11 was seated in a chair in his room receiving oxygen through a nasal cannula tubing from an oxygen concentrator running at five liters per minute. R11's oxygen humidifier bottle had approximately one eighth of an inch of water which was low enough that the oxygen supply was not touching the water to create any bubbles. R11's oxygen humidifier bottle and nasal cannula tubing were not dated to indicate the most recent time they were changed. R11's current physician order sheet dated 9/24/25 documents R11 is to receive oxygen therapy at two liters per minute at night and during naps, and at two liters per minute as needed during the daytime. This same physician order sheet documents R11's oxygen humidifier bottle and nasal cannula tubing are to be changed weekly on Tuesday nights (the most recent of which would have been 9/23/25). On 9/24/25 at 3:09 PM, V2 (Director of Nursing) stated R11's humidifier bottle would not have run down to the level of one eighth of an inch if it was changed according to the physician orders the night before on 9/23/25. The facility's policy Oxygen Administration dated as revised October 2010, provided by V15, Regional Nursing Consultant, documents the first step in administering oxygen to a resident is to verify there is a physician's order. This policy documents a Residents Affected - Few (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 09/24/2025 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)