Effingham Healthcare & Senior Living

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

would yell at anyone. V11 stated that if V4 raised his voice it was to talk over Resident R1. On 08/12/2025 at 2:28 PM, V4 (LPN) stated that one of the CNA's told him that Resident R1 was wanting a pain pill. V4 stated that he went into the room to tell Resident R1 that it was too early. V4 stated that Resident R1 accused him of yelling at Resident R1. V4 stated I was not trying to yell at Resident R1, I was trying to explain that he would have to wait one more hour because it was not time. V4 said he asked Resident R1 if he needed an ambulance. V4 stated that V11 (Regional Director) nor V2 (DON) called V4 to speak about this incident. On 08/13/2025 at 11:30 AM, V10 (LPN) stated she was the on call nurse the night of this incident. V10 said she never took a statement from V4, he was crying so much she could not understand him.On 08/13/2025 at 1:16 PM, V11 (Regional Director) stated that she only briefly spoke with V4, that she did not do an interview with him. V11 stated that she thought that V2 (DON) or V10 (LPN) spoke with V4.On 08/13/2025 at 1:35 PM, V2 (DON) stated that she did not do the investigation, that V11 completed the investigation because V1 was out of town. V2 stated that she spoke to V4 briefly, but he did not say much during the time she spoke to him. V2 stated she asked V4 what occurred but barely got any information out of him because he was still upset. On 08/15/2025 at 10:35 AM, V1 (Administrator in training) stated that she has no documentation of education for V4 for customer service and approach. V1 stated that she has reached out to V11 (Regional Director) to see if she has the education.2. Resident R6's admission Record documented a facility admission date of 11/03/2016 and included diagnoses of Alzheimer's Disease, hyperlipidemia, dementia, type 2 diabetes mellitus, dysphagia, developmental disorder of speech and language, convulsions, and essential hypertension. Resident R6's MDS assessment dated [DATE REDACTED] documented a BIMS score of 06, indicating Resident R6 has severe cognitive impairment. Resident R6's Care Plan with a revision date of 06/03/2025, includes a focus area of Resident R6 has a communication problem as evidenced by disruption in ability to speak. Resident R6 is non-verbal but does nod yes and no with her head. The interventions listed are acknowledge resident at each greeting, allow extra time for resident to respond, allow resident to complete thought process before responding, do not finish sentences for resident and anticipate and meet needs.A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/13/2025, Resident R1 reported that he has witnessed a staff member, V4, was yelling at a certain resident and other residents. Resident R1's handwritten letter (referenced above) also documented that Resident R1 has heard V4 yell at Resident R6 and other residents. On 08/13/2025 at 1:16 PM, V11 (Regional Director) stated

she did not complete a separate investigation for the allegation of abuse to Resident R6. V11 stated she just looked at it as one case. V11 stated that she did read the allegation on the handwritten letter that Resident R1 gave to her that had the allegation on it. On 08/13/2025 at 2:37 PM, V13 (Regional) stated they are starting an investigation regarding the allegation pertaining to Resident R6. Facility policy titled Abuse, Neglect, Exploitation or Misappropriation - reporting and investigating documented under policy statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

The same policy documents under section Investigating Allegations 1. All allegations are thoroughly investigated.7. The individual conducting the investigation at a minimum: . E. interviews any witnesses to

the incident. H. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. I. documents the investigation completely and thoroughly.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Effingham Healthcare & Senior Living

1610 North Lakewood Drive Effingham, IL 62401

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review, the facility failed to provide 8 hours per day, 7 days per week Registered Nursing (RN) coverage for the facility. This failure has the potential to affect all 37 residents residing in the facility. The facility's June 2025 Nurse Schedule documents on 06/01/25, 06/14/25, 06/15/25, 06/28/25 and 06/29/25 the facility did not have a Registered Nurse (RN) scheduled. On 06/04/25, 06/06/25, 06/09/25, 06/12/25, 06/20/25, and 06/26/25, V2 (Director of Nursing/DON) was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on the dates of 06/04/25, 06/06/25, 06/09/25, 06/12/25, and 6/26/25, V2 worked 7.5 hours, and on 06/20/25, V2 worked 7 hours. The facility's July 2025 Nurse Schedule documents on 07/05/25, 07/06/25, 07/26/25 and 07/27/25, the facility did not have an RN scheduled for 8 hours. On 07/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 07/09/25, V2 worked 7.5 hours. The facility's August 2025 Nurse Schedule documents on 08/06/25 and 08/10/25, the facility did not have a RN scheduled. On 08/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 08/09/25, V2 worked 3 hours. On 08/15/2025 at 9:47 AM, V2 (DON) stated that she is aware there is not RN coverage every day

on the schedule. V2 stated that there is a PRN (as needed) nurse who has recently started and is helping cover shifts. V2 stated the facility is advertising for a Registered Nurse position. V2 stated that this month is better than the last two with Registered Nurse coverage. On 08/15/2025 at 10:33 AM, V1 (Administrator) stated she is aware that they are short on RN coverage. V1 stated there is a RN job posted on Indeed for some time.The Minimum Data Set (MDS) Resident Matrix with a date of 08/12/25, documented 37 residents are residing at the facility.

Event ID:

Facility ID:

If continuation sheet