Inspection·June 25, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few well-being problem .5/27/24 (R3) was in an incident with a staff member with an allegation of verbal abuse The Interventions include, Social services will meet with (R3) twice weekly for 60 days to ensure he has no effects of alleged verbal abuse. On 6/20/24 at 2:53 PM, V4 (Certified Nursing Assistant/CNA) stated she was working with V21 (RN/Registered Nurse) and she had been stand-offish towards the residents. V4 stated she was sitting at the nurse's station charting and R3 rolled behind the desk and was sitting next to her. V4 stated R3 asked if they knew anything about small motors and V21 stated to R3, get out of here. V4 stated she suggested R3 go to his room or the dining room. V4 stated R3 stayed at the nurse's station and V21 told R3, I said get out of here, go on, get. V4 stated then V21 stated, If you don't get out of here on the count of 5, I am going to kick you in the forehead. V4 stated V21 then said and you don't know how high I can jump. V4 stated she backed R3 up and rolled him to his room and asked him to stay there. V4 stated she answered a call light and told V21 she would be back. V4 stated she went to the other hall and told the other nurse what had happened who reported it to the charge nurse. V4 stated the administrator was called and the other nurse's working walked V21 to the conference room. V4 stated they talked with V21 and then walked with her down the hall to do a narcotics count before walking her out the door. When asked if she felt like what occurred was abuse, V4 stated, Yes, the look on her (V21) face made it look like she meant it. V4 stated it was a hey, get away from me or else I am going to hurt you. When asked if she felt like the facility handled it appropriately, V4 stated, Yes, they walked her out. V4 stated as far as she knows V21 had not been back to the facility. The untitled statement included in the abuse investigation signed by V21 (RN,Registered Nurse ) documents, (R3) approached desk CNA and nurse were at. He (R3) said something very sexual. I was upset, as I've been assaulted before and have not slept in nearly 24 hours. I don't recall what I said beyond trying to get him away On 6/25/24 at 2:03 PM, V2 (Director of Nurses) stated administration was notified V21 had threatened to kick R3 in the forehead. V2 stated they immediately got V21 and had her count narcotics with another nurse, and then sent V21 home. V2 stated they contacted V21's agency employer and told them they had sent her home due to an allegation of abuse. V2 stated they started the investigation and determined abuse had occurred. V2 stated they notified V21's employer that the allegation was founded. V2 stated V21 said she didn't recall her exact words to R3. V2 stated they educated all staff on abuse/neglect on 5/27/24, they conducted a QAPI (Quality Assurance and Performance Improvement) meeting on 5/28/24, interviewed the residents on 5/27/24, and are completing on-going audits. The facility Abuse, Prevention and Prohibition Policy dated 01/24 documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Under Prevention the policy documents, the resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 2 of 3 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 06/25/2024 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)

F 0600 not abuse or neglect a resident and must prohibit the misappropriation of resident property Level of Harm - Minimal harm or potential for actual harm Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. R3 was assessed and no injuries were noted. R3 was interviewed and does not recall the incident. Residents Affected - Few 2. The nurse, V21 was immediately sent home. 3. Direct care staff were provided education on the abuse policy and customer service on 5/27/24. 4. All residents have the potential to be affected by the alleged deficient practice. Only one (R3) was identified. 5. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting held on 5/28/24, with the IDT (Interdisciplinary) team, the plan to address the area of concern was discussed. 7. On 5/26/24 and 5/27/24 interviewed all alert residents on (R3's) hall to ask if they have had any issues with staff abuse. 6. Administrative team will monitor 3 times weekly for 60 days using monitoring form designated for this PNC (past non-compliance). All patterns and trends will be brought to QAPI for changes as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 3 of 3