Inspection·June 11, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide daily denture/oral hygiene care for 4 of 4 residents (R1, R7, R5, R6) reviewed for ADL (Activities of Daily Living) care in the sample of eleven. Residents Affected - Some Findings include: 1. R1's Face Sheet documented an admission Date of 12/27/23 and listed diagnoses including Congestive Heart Failure, Anxiety Disorder, and Chronic Kidney Disease. R1's 1/5/24 Minimum Data Set (MDS) documented that R1 had severe deficits in cognitive function and required moderate assistance from staff for oral hygiene and denture care . On 6/4/24 at 8:20am, V4, Family Member of R1, stated she had noted on several occasions that R1's dentures were yellow, odorous, and covered with layers of caked on food particles. 2. R7's Face Sheet documented an admission Date of 8/19/17 and listed diagnoses including Multiple Sclerosis and Diabetes Type 2. R7's 3/2/24 MDS documented that R6 had minimal deficits in cognitive functioning, had range of motion impairment to both upper extremities, and requires set up and clean up assistance for oral hygiene and denture care. On 6/5/24 at 9:40am, R7 was alert and oriented. R7 stated staff do not offer to help or remind her to clean her dentures. R7 stated staff will help her to clean them only if she asks, and, Some (staff) are more willing than others. 3. R5's Face Sheet documented an admission Date of 1/12/24 and listed diagnoses including Diabetes Type 2 and history of Cerebral Infarction. R5's 4/18/24 MDS documented that R5 had minimal deficits in cognitive functioning, and that R5 requires set up and clean up assistance for oral hygiene and denture care. On 6/5/24 at 10:10am, R5 was alert and oriented. R5 stated she took out her top dentures and put them on the bedside table 2 weeks ago and hasn't seen them since, despite staff searching for them. R5 stated she has a dental appointment later this week to get impressions made for a new set. R5 stated she has some of her own teeth on the bottom. R5 stated the only time staff assist her with denture and oral care is when they have CNA (Certified Nursing Assistant) students working. R5 stated CNA staff are usually too busy to assist with denture care. 4. R6's Face Sheet documented an admission Date of 5/18/22 and listed diagnoses including Atrial Fibrillation, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. R6's 5/6/24 MDS documented that R6 had severe deficits in cognitive functioning, had restricted range of motion in both upper (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 5 Event ID: 145256 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 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street 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)