Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, and record review the facility failed to ensure residents were safe from
misappropriation of a controlled substance medication for 1 of 3 residents (R2) reviewed for
misappropriation in a sample of 8.
Residents Affected - Few
The findings include:
R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The
Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but
when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been
made. The facility has initiated an investigation into the matter. A final report will follow.
R2's facility Final Report dated 8/26/24 documents in part: The purpose of this letter is to notify The
Department of our conclusion of the investigation into a possible drug diversion. Licensed staff had
administered the resident's 8 am dose. At 10 am when the Licensed Nurse went to administer the
morphine, the bottle of morphine could not be located. The physician, POA (Power of Attorney), (City)
Police and the Ombudsman were notified. The Administrator and Nursing Administration initiated a search
of the facility and facility grounds. The medication was not located. An investigation was initiated. The
Licensed Nurse, (V4) was overseeing the medication cart. He was suspended pending the outcome of the
facility. The hospice nurse was notified of the Morphine bottle not being located. The facility asked Hospice
to replace the Morphine and bill the facility. The Morphine was replaced. Licensed staff initiated a pain
assessment. (R2) showed no changes in his pain level. Residents were interviewed. Residents were not
aware of any issues with medications and had not observed the medication. All staff working were
interviewed. Staff stated that they had not observed the morphine out of the cart and had no knowledge of
where the medication was. (V11) LPN (Licensed Practical Nurse) was the night shift nurse and was still
working till approximately 10:30 am finishing the charting for her shift. (V11) stated that the medication cart
was in front of the nurse's station. She stated that (V4) had administered the 8 am dose of Morphine. (V11)
said that she did not observe (V4) place the Morphine bottle in the cart and lock it as she had her back to
him charting at the nurse's desk. (V11) stated at approximately 10:00 am (V4) went to the medication cart
to administer the 10:00 am dose of Morphine and he stated it was not in the cart. She stated that he began
looking for the medication and Nurse Management was notified. (V11) was asked if she observed the bottle
of Morphine on top the cart and she stated No, she did not. She was also asked if the medication cart was
locked. She stated that she was finishing charting, and her back was toward the cart. (V4) LPN was
interviewed by the Director of Nursing and Regional Nurse via phone. He stated that he had given the
resident his 8 am dose of medication. (V4) stated he placed the empty syringe back into the morphine box
and placed everything in the medication cart and locked the cart. He stated that at approximately 10 am he
went to the cart, unlocked the cart, and was going to give the medication but was unable to locate
(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 9
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
10/10/2024
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 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the morphine in the cart. (V4) stated that he searched the cart and could still not locate the medication. He
stated that he checked the trash can on the med cart and at the nurse's desk. (V4) stated that he checked
the second medication cart and the treatment cart but was not able to locate the medication. He then
notified Nurse Management and Nurse Management began looking for the Morphine. (V4) was asked if he
placed the medication back in the cart and locked the cart after administering the 8 am dose and he said
yes, that is my routine. He was asked if he unlocked the cart when he was getting ready to administer the
10 am dose and he said yes. (V4) said after he was sent home, he was retracing his steps in his head and
was second guessing everything he did. (V4) denied taking the medication and volunteered for drug testing.
(V4) submitted a drug test, and the results were negative. An audit of all narcotics in the facility was
completed and no other issues were noted. Following the investigation, based on interviews, the facility is
not able to determine what happened to the morphine and cannot substantiate drug diversion. There is no
evidence indicating (V4) took the medication. The facility is unable to locate the Morphine, and the search is
ongoing. The morphine was replaced at the cost of the facility. All Licensed staff were educated by the
Director of Nursing regarding Medication Administration, medication storage, and narcotic count between
shifts. (V4) will be allowed to return to work. Prior to returning to work, the Director of Nursing completed
education regarding Medication Administration, medication storage, and narcotic count between shifts.
R2's admission record documents an admission date of 6/26/24 and a discharge date of 9/29/24. with
diagnoses in part; encounter for palliative care (admitting diagnosis), atherosclerotic heart disease, chronic
obstructive pulmonary disease, chronic kidney disease, heart failure, chronic pain, colostomy status,
cervicalgia, osteoarthritis, chronic pulmonary embolism.
R2's order summary report documents in part an order dated 7/29/24, resident is under Transition hospice
care.
R2's Medication Administration Record (MAR) for September, with a print date of 10/8/24 documents an
order for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth
every 2 hours for pain with a start date of 8/24/24. R2's MAR documents that he received his scheduled
doses of Morphine at 8:00 and 10:00am on 9/20/24.
A facility document titled INDIVIDUAL RESIDENT CONTROLLED SUBSTANCE RECORD dated 8/19/24
with R2's name handwritten on it documents the medication as Morphine Sulfate 20mg/ml and the quantity
received as 30ml. The last documented dose administered on this document is on 8/20/24 at 9:00am, the
amount given is 0.5 with 24ml remaining. R2's ordered dose was 0.5mg, indicating there were 48 doses left
in the bottle.
On 10/8/24 at 12:03pm, V5 (Licensed Practical Nurse/LPN) stated she was here the day the morphine went
missing, everyone was looking for it. It was never found. There was big investigation done and lots of
education and inservice.
On 10/9/24 at 12:29pm, V2 (Director of Nursing) stated as soon as they were alerted that morphine was
missing, they contacted hospice and started the process of getting a replacement. V2 stated they received
the medication very quickly; the pharmacy delivered it and R2 received the dose within the appropriate time
frame. V2 stated R2 was being assessed for pain frequently while waiting for the replacement bottle. V2
stated the missing bottle was never located after a search of the property and investigation.
On 10/9/24 at 03:15pm, V4 (LPN) stated there was no narcotic count completed between himself and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 2 of 9
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
10/10/2024
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 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
V11 (LPN) after he took over the med cart. V4 stated he counted by himself at one point, and everything
was fine. V4 stated he is certain he drew up R2's medication and locked the bottle back into the cart, as
that is his common practice. V4 stated that since this incident happened, he has been replaying it in his
mind and second guessing himself, however he stated he sees no reason why he would have done things
any differently. V4 stated he was the only one suspended and investigated. V4 stated the other nurse
working with him told him and administration there was a CNA that does transport standing by his cart, she
then went to the bathroom and went to a patient room. V4 stated that this CNA was questioned, but not
investigated. V4 stated the medication was never found.
The Facility's Abuse, Prevention and Prohibition Policy revised 1/24 documents in part, 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 also prohibits misappropriation of resident property.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 3 of 9
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
10/10/2024
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to prevent residents from receiving medical treatment without
a doctor's order for 1 (R1) of 3 residents reviewed for physician's orders in a sample of 8.
Residents Affected - Few
Findings include:
R1's admission record documents an admission date of 02/20/24 with diagnoses in part; type II diabetes
mellitus with hypoglycemia without coma, paroxysmal atrial fibrillation, other seizures, unspecified
convulsions. R1's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview for mental
status) of 12, indicating that R1 is cognitively intact .
R1's order summary sheet documents an order for ACCUCHECK every two hours from the ER (Emergency
Room) for hypoglycemia with a start date of 3/4/24 and a discontinue date of 6/20/24.
On 3/19/24 R1's Medication Administration Record documented accuchecks every two hours, most of R1's
accuchecks were between 80 and 162, which is not considered to be hypoglycemic. There is an accucheck
at 12pm of 46, which is considered hypoglycemia, but there is no further documentation in R1's clinical
record, including progress notes.
R1's order summary sheet documents an order for Glucagon Emergency Injection Kit, 1 MG (milligram)
(Glucagon (rDNA))-Inject 1 application intramuscularly as needed for low blood sugar with a start date of
2/20/24. There is no documentation that the glucagon was administered on 3/19/24.
On 10/8/24 at 1:40pm, R1 stated his blood sugars have been pretty good lately and he could not recall if
anyone tried to start an IV on him in this facility.
On 10/8/24 at 1:51pm, V2 (Director of Nursing/DON) stated they had an incident in March involving V3
(Licensed Practical Nurse/LPN) attempting to start an IV (intravenous) without a physician's order. V2
stated V3 was not successful starting the IV, no medications were administered, but V3 was disciplined,
and staff education was done. V2 stated V3 had spoken with V6 (the nurse at the doctor's office) previously
about this resident and V6 stated if R1 continued to have such drastic drops in his blood sugar they would
need to get a standing order to give dextrose via IV. V2 stated V6 did not give a standing order at that time.
V2 stated that they do not have a specific policy or protocol to low blood sugars, but each resident who is
under blood glucose monitoring should have standing orders for such situations.
On 10/08/24 at 1:51pm, V2 (DON) provided a copy of facility document titled Employee disciplinary action
form for V3 with an incident date of 03/19/24 stated V3 did not follow departmental Policies and procedures.
This document further stated that V3 did not get an order from MD prior to initiating a medical
procedure/medication and that there was no documentation of residents low CBG (Capillary Blood
Glucose). V2 provided a statement from V6 that she did not give a standing order for IV dextrose and a
signature sheet from their staff in-service.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 4 of 9
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
10/10/2024
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide adequate supervision for residents with dementia
for 2 (R3 and R4) of 5 residents reviewed for dementia care services in the sample of 8.
Residents Affected - Few
Findings include:
A facility incident report dated and timed 9/15/24 at 11:08am, documents the following incident description
in part: A Housekeeper helping another patient to her room walking in room [ROOM NUMBER]. When
opened room [ROOM NUMBER] housekeeper witnessed (R4) standing in front of female patient with his
pants open and down-with suspenders holding pants part way up. Female resident was in her room on her
bed, fully clothed. Female patient had her mouth open providing oral sex to (R4). (R4) turned around and
pulled up his pants, he told staff he was receiving help with is belt. Both patients immediately separated
themselves, he went to his room. Female patient states she thinks (R4) is her husband and she wants to be
with him. When staff asked (R4) if he knew her, he says he doesn't know her, just some lady around here.
He said he needed help adjusting his belt. He denied what was going on. He asked if they were in trouble .
An investigation was initiated following the interaction. Staff present at the time of the incident were
interviewed. (R3) stated she didn't understand why staff won't let me be with my husband. Both residents
were put on 1:1 for 24 hours after the incident. Both resident's Physicians were notified, and no new orders
were received. There have been no further incidents. Residents were interviewed. The residents
interviewed have had no issues with either of the residents involved. (R3) was interviewed. She does not
recall the incident. (R4) was interviewed. He does not recall the incident. The Ombudsman was notified and
stated that both parties were consenting. A trauma assessment was completed for both residents,
identifying no new issues. Behavior tracking was initiated for both residents. Their care plans were reviewed
and updated. Social services will visit with each resident twice weekly for 30 days. After reviewing the
incident, it is our conclusion that during the incident both residents were consenting adults.
A facility correspondence with IDPH titled Final Report dated 09/20/24 documents in part: The purpose of
this letter is to notify The Department of our conclusion to a reported incident. On 9/15/24, staff observed
an interaction between two residents, (R3) and (R4). Staff immediately separated the residents. Licensed
Staff initiated a head-to-toe assessment noting no injuries. MD( Medical Doctor) and POA (Power od
Attorney) made aware. Local police were notified. Ombudsman was notified.
On 10/08/24 at 2:51pm, V1 Administrator stated that the incident on 9/15/24, between R3 and R4 was
consensual, but provided no evidence during this investigation that R3 and R4 had been screened and
identified as having the cognitive ability to provide consent.
1. R4's admission record documents an admission date of 8/27/2024 with the diagnoses in part:
Alzheimer's disease, other symptoms and signs involving cognitive functions and awareness, altered
mental status.
R4's Minimum data set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 3,
indicating that R4 is severely cognitively impaired.
R4's current care plan documents a focus area of inappropriate sexual behavior. With an initiation date of
9/16/24 and a revision date of 9/27/24 with interventions including in part: Behavior #1:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 5 of 9
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
10/10/2024
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 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Inappropriate sexual conduct towards others (i.e.: inappropriate touching, purposeful exposure of genitals
to others, etc.) Remove from area, ensure (R4)'s safety, encourage to discuss feelings, try a different care
giver, offer to call family. Monitor behavior episodes and attempt to determine underlying cause.
R4's POC response history with a print date of 10/8/24 documents that R4 displayed inappropriate sexual
conduct toward others on 9/24/24 and 10/1/24, intervention used for both occurrences was redirection.
R4's progress notes document in part the following:
On 9/15/24 at 1:42pm, (R4) was looking for female friend and went into her room looking for her .staff
asked him to get out of her room and he became agitated.
On 9/15/24 at 2:02pm, (R4) was standing outside lady friend's room, waiting on her to come to her room it
appears. Staff asked him what he was doing. He said he's looking for someone. Asked to stay out of room
[ROOM NUMBER]. Informed him 121 was a female room. He opened the door twice and was inside once.
On 09/16/2024 at 4:20pm, SSD (Social Services Director) met with (R4) today and conducted BIMS, PHQ9
(Patient Health Questionnaire-9) , and trauma informed consent. (R4) states he feels safe in his
environment. No other concerns at this time.
On 9/22/24 at 2:48am, Resident was seen wandering into another resident's room, resident went into a
female resident's room and was trying to wake her to leave, resident was redirected back to bed by staff,
continue to monitor closely. Continue current plan of care.
On 9/27/24 at 9:05am, Resident went into a female resident's room and was trying to get her to go with
him.
On 9/27/24 at 1:59pm, Resident was in another female resident's room. Redirected back to his room.
On 10/1/24 at 10:01am, Resident tried to get female resident to go in his room. The other resident refused,
and he stated, I guess you don't want to have sex with me.
On 10/9/24 at 12:30pm, V8 (Registered Nurse/RN) stated it is known that they are supposed to keep a
close eye on R4 but there really isn't anything specifically laid out in his care plan or behavior tracking
related to his level of supervision. V8 stated that R4 was supposed to be one on one for the first 24 hours
after the incident happened. V8 stated she was not familiar if there was anything that the CNA's were
supposed to chart specifically but nurses were expected to chart on R4 any time a behavior is observed.
On 10/9/24 at 1:15pm, V9 (Restorative Aide) stated that everyone on the unit is to be under close
supervision. V9 stated he was not sure if there was any specific supervision in place for R4.
2. R3's admission record documents an admission date of 7/16/24 with diagnoses including in part;
Alzheimer's and dementia.
R3's Minimum Data Set (MDS) documents a Brief Interview for Mental status (BIMS) of 07, indicating
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 6 of 9
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
10/10/2024
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 0744
that R3 is severely cognitively impaired.
Level of Harm - Minimal harm
or potential for actual harm
R3's current care plan documents a focus area of inappropriate sexual behavior. With an initiation date of
9/16/24 with interventions including in part: Behavior #1: Inappropriate sexual conduct towards others (i.e.:
inappropriate touching, purposeful exposure of genitals to others, etc.) Remove from area, ensure (R3)'s
safety, encourage to discuss feelings, try a different care giver, offer to call family. Monitor behavior
episodes and attempt to determine underlying cause.
Residents Affected - Few
On 9/15/2024 at 11am, Roommate came to housekeeper and said she needed help getting in her room.
Housekeeper was helping 121-2 patient back to her room, she knocked on the door 121 and opened it for
roommate to walk in. Housekeeper witnessed (R3) sitting on bed fully clothed with her mouth open giving
oral sex to a male patient. Male patient was standing in front of her with his pants open and down-with
suspenders holding pants part way up. Male resident turned around and pulled up his pants, he said he
was receiving help with is belt. (R3) and male patient immediately separated themselves, he went to his
room. (R3)'s face was red. She appeared embarrassed. She asked why she can't be with her husband .
(her husband is not here/alive) Re-oriented her that she is in nursing home and her husband is no longer
around. (R3) insist we separated her from her husband and is asking why. (R3) said she brought him to her
room. Male patient says he doesn't know her, just some lady around here he said .
On 9/16/24 at 4:17pm, SSD (Social services director) met with (R3) today. Conducted BIMS, PHQ9 (Patient
Health Questionnaire-9), and trauma informed consent. (R3) was very confused today and displayed
disorganized thinking. She states she feels safe in her environment.
On 10/9/24 at 1:21pm, R3 was observed ambulating down the hallway away from her room. R3 stopped
and proceeded to stand in R4's doorway and then walked inside while R4 was laying on his bed. Staff was
alerted and redirected R3.
On 10/9/24 at 1:27pm, V10 (CNA/Certified Nursing Assistant) stated everyone on the locked unit is under
close supervision. V10 stated R3 and R4 were both in the unit on 9/15/24. V10 stated R3 and R4 were both
one on one supervision for the first 24 hours after the incident. V10 stated they really try to prevent anyone
going into the room of someone of the opposite sex. V10 stated that they do chart behaviors if R4 has
them, but that they do not have any specific time frame for checking on him.
There is no documentation in R3 or R4's current clinical records of any discussion or education with them,
their representative, or physician regarding consent. There is nothing in R3 and R4's care plans regarding
consent.
Facility document titled, Abuse, Prevention and Prohibition with a revision date of 1/24, under the section
titled Protection, The facility will immediately remove any alleged perpetrator from any further contact with
any resident. Further on in this document in the section Resident capacity to consent to sexual activity it
states generally, sexual contact is nonconsensual if the resident appears to want the contact to occur but
lacks the cognitive ability to consent. This document states that if there are 2 residents who wish to have a
sexual relationship, the following steps will be followed: A one-on-one discussion with each individual must
be held to ensure they are consenting to an intimate relationship with the other resident. The discussion will
define the type of relationship that is desired. For a resident who DOES NOT have the capacity to consent,
the Resident Representative will be contacted to discuss resident wishes. If the Resident Representative
DOES NOT AGREE with the resident choice, then there will be a resident, Resident Representative, IDT
meeting to discuss plan
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 7 of 9
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
10/10/2024
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 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
of care. Provider will be notified of resident and Resident Representative wishes. Discussion and consents
to be documented in the clinical record and care plan updated to reflect the resident and/or Resident
Representative wishes. Education will be provided to both residents involved and when appropriate the
Resident Representative on risk vs. benefits of the relationship, what is consented by both parties, and any
safety information needed. The Education provided will be documented in the clinical record and the care
plan updated.
Event ID:
Facility ID:
145256
If continuation sheet
Page 8 of 9
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
10/10/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on interview and record review, the facility failed to consistently and accurately reconcile narcotic
medication counts in accordance with professional standards of practice for 1 of 3 residents (R2) reviewed
for narcotic medication in a sample of 8.
The findings include:
R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The
Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but
when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been
made. The facility has initiated an investigation into the matter. A final report will follow.
R2's facility Final Report dated 8/26/24 documents in part an undated and untimed interview with V11
(LPN/Licensed Practical Nurse). V11 stated she stayed over from midnight shift to help pass the back half
of 300 hall medications. V11 stated she and V4 (LPN) counted the narcotics for the front part of the hallway
but not the back because she was still using the cart to pass medications. V11 stated R2's narcotic
medication was on the cart for the back half of the hall. V11 stated she gave V4 the keys for the cart for the
back half between 9:00am and 9:15am and they did not perform a count.
On 10/9/24 at 03:15pm, V4 (LPN) stated there was no narcotic count completed between himself and V11
(LPN) after he took over the med cart. V4 stated he counted by himself at one point, and everything was
fine.
On 10/8/24 at 12:03pm, V5 (LPN) stated count should be done anytime a nurse is taking over responsibility
of a med cart from another nurse.
On 10/9/24 at 10:07am, V7 (RN/Registered Nurse) stated count should be done anytime you are assuming
responsibility from someone else for those medications.
On 10/09/24 at 2:20pm, V2 (DON) stated that narcotics should be counted any time that a nurse is taking
over responsibility for the cart and before anyone leaves.
A facility document titled, Employee corrective action form for V4 dated 8/20/24 documents in part a failure
to follow departmental policies and procedures, by not counting narcotics with nurse from previous shift and
not properly storing narcotics after administration.
A facility document titled, Employee corrective action form for V11, dated 08/20/24 documents in part a
failure to follow departmental policies and procedures, by not counting narcotics with oncoming nurse.
Facility controlled substance policy documents in part; The persons performing the inventory will sign to
verify that the inventory was done. All controlled substances are to be counted every shift. The count is to
be performed by the oncoming licensed nurse here applicable and the off-going licensed nurse where
applicable.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145256
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F602 - The resident has the right to be free from abuse, neglect, misappropriation of re
Protect each resident from the wrongful use of the resident's belongings or money.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the October 10, 2024 survey of LAKELAND REHAB & HEALTHCARE CENTER?
This was a inspection survey of LAKELAND REHAB & HEALTHCARE CENTER on October 10, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LAKELAND REHAB & HEALTHCARE CENTER on October 10, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from the wrongful use of the resident's belongings or money."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.