Effingham Healthcare & Senior Living

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.

Based on observation, interview and record review, the facility failed to keep resident rooms clean for 1 (Resident R5) of 3 residents reviewed for homelike environment out of the sample of 7. Findings Include:Resident R5's admission

Record documented an admission date of 11/21/2025. This same record documented diagnosis including cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, ST-elevation myocardial infarction of unspecified site, and presence of aortocoronary bypass graft. On 11/22/25 at 11:51 AM, an observation in Resident R5's room revealed the following: 5 separate fecal matter smeared areas on the floor between bed 1 and bed 2.On 11/22/2025 at 12:00PM, an observation of 5 separate areas of fecal matter still smeared on the floor in Resident R5' room between bed 1 and bed 2 after observing V3 (Housekeeping) clean Resident R5's room including sweeping and mopping the floor.On 11/22/2025 at 12:10 PM, V3 (Housekeeping) stated she had swept and mopped Resident R5's room.On 11/22/2025 at 12:18 PM, V1 (Administrator) stated her expectations would be for the housekeeping staff to clean resident rooms per the facility policy, including cleaning the fecal matter off the floor.On 11/24/2025 at 11:15 AM, Resident R5 who was alert and oriented stated he had been in the facility for a few days. Resident R5 stated, the facility does not clean very well and does not clean his room daily. On 11/24/2025 at 11:16 AM an observation in Resident R5's room revealed fecal matter in the same area as noted on 11/22/2025 between bed 1 and bed 2 still smeared on the floor. The facility policy titled Homelike Environment (revised February 2021) documents under Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. This same document under Policy Interpretation and Implementation documents under step 2, the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: a. clean, sanitary and orderly environment.

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

Event ID:

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

11/26/2025

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

trained. V13 stated she should have applied the enhanced barrier precautions prior to starting Resident R1's care.On 11/24/2025 at 2:10 PM, V2 (Director of Nursing/DON) stated her expectation for perineal and bowel incontinence care is all staff to follow policy and procedure.On 11/24/2025 at 2:30 PM, V1 (Administrator) stated her expectation is for all staff to follow policy and procedure for perineal and bowel incontinence care.The facility policy titled Perineal Care (revised February 2018) documents Purpose: The purpose of

this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This same document under Equipment and Supplies documented, the following equipment and supplies will be necessary when performing this procedure: 1.

Wash basin, 2. Towels, 3. Washcloth, 4. Soap (or other authorized cleaning agent) and 5. Personal protective equipment (e.g. gowns, gloves, mask, etc., as needed). Steps in the Procedure documented 1.

Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half full of warm water. Place the wash basin on

the bedside stand within reach.The Centers for Disease Control guidance for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated 4/2/24 found at www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html documents under Enhanced Barrier Precautions The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Event ID:

Facility ID:

If continuation sheet