Health inspection·July 28, 2025

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete antibiotics both with a revision date of 7/14/25. Documented interventions include staff will wear gown and gloves when performing high-contact resident care with an initiation date of 04/05/2024.On 7/23/2025 at 9:05 AM, V10 administered IV medication to R118. V10 applied a gown at the door then performed hand hygiene and applied gloves to give R118 IV medication. V10 then went into the bathroom and grabbed the IV pole and brought it next to R118, then V10 reached into her shirt pocket and took out supplies with the same gloves on. With the same gloves on V10 then prepped the IV medication and tubing then hung it on the IV pole, then removed the cap from the PICC line access, cleaned it with alcohol and then connected the IV tubing to the PICC line access. V10 did not change gloves throughout the entire observation. On 7/23/2025 at 10:43 AM, V10 stated she forgot to put on a gown before she entered R117's room to administer the IV medication. V10 stated she should have worn a gown into R117's room because he is on contact isolation and enhanced barrier isolation. V10 stated she usually puts on gloves when she gets into the room then gathers supplies and gets the supplies ready for use and does not usually change gloves before she accesses the IV access line. V10 stated she doesn't know what the policy says about when to change her gloves and she didn't receive any special training on the procedure of accessing IV's at the facility.On 7/24/2025 at 10:09 AM, V2 (Director of Nursing) stated she expects the nurse to wear clean gloves when accessing the IV and if the nurse touches anything else prior to accessing the IV line then they should change their gloves and perform hand hygiene right before they access the IV. V2 stated R117 is on contact isolation and enhanced barrier isolation and a gown should be worn by all staff anytime care is being performed so V10 should have worn a gown when administrating the IV medication. V2 stated the facility does not have a policy or procedure for preparation, administration, or maintenance related to IV therapy. V10 stated they do not provide training at the facility on administrating IV therapy, the nurse should already know how to do that. Event ID: Facility ID: 145256 If continuation sheet Page 2 of 6 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 07/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure menus were followed for 4 of 6 (R57, R24, R13, and R119) residents reviewed for nutrition in the sample of 56. Findings include:1. R57's admission Record with a print date of 7/24/25 documents R57 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, morbid obesity, dementia, and gastroesophageal reflux disease.R57's MDS (Minimum Data Set) dated 5/31/25 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating a severe cognitive deficit.R57's current undated Care Plan documents a Focus area of (R57) has nutritional problem or potential nutritional problem, altered diet. Regular diet, pureed texture, nectar thick liquids. This same Focus area includes an intervention to Provide, serve diet as ordered. Monitor intake and record q (every) meal.R57's Medication Review Report dated 7/24/25 documents a physician order for regular diet, pureed texture, nectar thick liquids with a start date of 5/22/25.On 07/21/2025 at 1:10 PM, R57 was served a pureed diet in three bowls. One bowl with catfish, one with rice, and one with vegetables and a small dessert bowl with pudding. There was no pureed bread served to R57 with this meal.2. R24's admission Record with a print date of 7/24/25 documents R24 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease and dysphagia.R24's MDS dated [DATE] documents a BIMS score of 10, indicating a moderate cognitive deficit.R24's current undated Care Plan documents a Focus area of (R24) has potential nutritional problem. At risk for wt (weight) loss r/t (related to) dementia. This same Focus area includes an intervention of, Provide, serve diet as ordered. Monitor intake and record q (every) meal.R24's Medication Review Report dated 7/24/25 documents a physician order for regular diet, pureed texture, nectar thick liquids, no straws, intolerance to red dye for nutrition with a start date of 6/24/24.On 07/21/2025 at 1:10 PM, R24 was served pureed foods in three separate bowls. One bowl with what appeared to be fish, one with what appeared to be rice, one with what appeared to be vegetables, and a dessert bowl with what appeared to be pudding. R24 was not served a pureed dinner roll.3. R13's admission Record with a print date of 7/24/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include age related cognitive decline, dementia, and gastroesophageal reflux disease.R13's MDS dated [DATE] documents a BIMS score of 08, indicating a moderate cognitive impairment.R13's undated current Care Plan documents a Focus area of, (R13) has nutritional problem on altered diet, at risk for wt loss. Regular diet, pureed texture, nectar thick liquids.R13's Medication Review Report dated 7/24/25 documents a physician order for regular diet pureed texture, nectar thick liquids with a start date of 7/19/25. On 07/21/2025 at 12:56 PM, R13 was served four bowls of pureed food. One appeared to be fish, one rice, one a vegetable, and one pudding.4. R119's admission Record with a print date of 7/24/25 documents R119 was admitted to the facility on [DATE] with diagnoses that include heart disease, gastroesophageal reflux disease, and pneumonitis due to inhalation of food and vomit.R119's undated current Care Plan documents a Focus area of, The resident has nutritional problem, or potential nutritional problem . This same Focus area includes the intervention of Provide, serve diet as ordered.R119's Medication Review Report dated 7/24/25 documents a physician order for regular diet pureed texture, nectar thick liquids with a start date of 7/21/25.On 7/21/2025 at 1:30pm, R119 was served a pureed diet and was assisted to eat by V7 (Infection Preventionist). R119's tray was noted to have pureed fish, pureed wild rice, pureed mixed vegetables, and banana pudding, but did not include a pureed roll. When V7 was asked what R119 was served for his noon meal, V7 replied, fish, veggies, rice, and banana pudding.The facility Master Menu dated 7/23/25 documents the pureed diet for 7/21/25 as roll wheat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 3 of 6 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 07/28/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete .fried catfish deep fried, rice long grain and wild, veg (vegetable) mix roasted [NAME], pudding banana On 07/23/2025 at 1:40 PM, when asked why R13, R24, R57, and R119 were not served a pureed dinner roll with their noon meal on 7/21/25, V3 (Dietary Manager) stated they were probably just missed.On 7/24/25 at 2:01 PM, V1 (Administrator) stated she would expect residents who are served a pureed diet to get all of the menu items as they should.The facility Therapeutic Diets policy dated 12/2024 documents, Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possible dietary restrictions. 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. 2. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. 3. A therapeutic diet must be prescribed by the resident's Attending Physician. The Physician's diet order should match the terminology used by Food Services. Event ID: Facility ID: 145256 If continuation sheet Page 4 of 6 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 07/28/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure proper infection prevention and control practices were used during resident care for 2 of 5 residents (R117 and R118) observed for infection prevention and control in the sample of 56.Findings include:1. R117's admission Record documents an initial admission date of 10/23/2023 and diagnoses including in part sepsis, infection, and inflammatory reaction due to indwelling urethral catheter, stage 3 pressure ulcer of right heel and left heel, and osteomyelitis of ankle and foot.R117's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 indicating R117 has intact cognition.R117's Order Summary Report dated 7/24/2025 documents and order to flush Peripherally Inserted Central Catheter (PICC) with 10 milliliters (ml) of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/21/25, R117 required enhanced barrier precautions related to wounds, urinary catheter, and PICC line with an order date of 7/15/25, and Daptomycin sodium chloride intravenous (IV) solution one time a day for sepsis/osteomyelitis for 35 days with a start date of 7/19/25. R117's most recent Care Plan documents a focus area of R117 is on enhanced barrier precautions due to urinary catheter, wounds, and PICC line with an initiated date of 7/18/2025 and interventions including in part staff will wear gown and gloves when performing high-contact resident care activities. Focus areas from the same Care Plan document R117 is on IV daptomycin for osteomyelitis with an initiated date of 7/18/2025 and R117 has a PICC line with an initiated date of 7/18/2025.On 7/23/2025 at 8:41 AM, V10 (Registered Nurse) administered IV medication to R117. V10 applied gloves at the doorway without performing hand hygiene first when entering the room to give R117 IV medication. V10 then moved the IV pole closer to R117 then pulled all the supplies out of her pocket and organized things on the bed side table with the same gloves on. With the same gloves on V10 then prepped the IV medication solution and hung the IV medication bag on the pole, removed the cap from the PICC line access and scrubbed the end of the PICC line with an alcohol pad, and connected the IV tubing to the PICC access site. V10 did not change gloves or wear a gown throughout the entire observation. On 7/23/2025 at 9:58 AM, V11 (Certified Nursing Assistant/CNA) and V12 (CNA) performed urinary catheter care on R117. V11 cleaned R117 with a soapy wet washcloth, then changed gloves without performing hand hygiene between glove changes, wiped R117 with a wet washcloth, changed gloves without performing hand hygiene between glove changes, then dried R117 with a dry towel. V11 and V12 then removed gloves and performed hand hygiene. On 7/24/2025 at 1:16 PM, V11 stated she usually performs hand hygiene when she changes gloves, but she must have forgotten. V11 stated the hand sanitizer was in her pocket. V11 stated she should have performed hand hygiene between glove changes.2. R118's admission Record documents an initial admission date of 5/6/2021 and diagnoses including in part sepsis, urinary tract infection, infection, and inflammatory reaction due to indwelling urethral catheter, and pneumonia.R118's MDS dated [DATE] documents a BIMS score of 14 indicating R118 has intact cognition.R118's Order Summary Report dated 7/24/2025 documents flush PICC line with 10 ml of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/23/25 and R118 requires enhanced barrier precautions per Illinois Department of Public Health guidelines related to urinary catheter and IV site with an order date of 7/22/25. R118's Order Details documents Ertapenem Sodium Solution Reconstituted 1 gram, give one gram intravenously every 24 hours for infection for 12 days with an order date of 7/11/25.R118's most recent Care Plan documents a focus area of R118 is on enhanced barrier precautions due to urinary catheter, wounds, and IV access and R118 has IV antibiotics both with a revision date of 7/14/25. Documented interventions include staff will wear gown and gloves when Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 5 of 6 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 07/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete performing high-contact resident care with an initiation date of 04/05/2024.On 7/23/2025 at 9:05 AM, V10 administered IV medication to R118. V10 applied a gown at the door then performed hand hygiene and applied gloves to give R118 IV medication. V10 then went into the bathroom and grabbed the IV pole and brought it next to R118, then V10 reached into her shirt pocket and took out supplies with the same gloves on. With the same gloves on V10 then prepped the IV medication and tubing then hung it on the IV pole, then removed the cap from the PICC line access, cleaned it with alcohol and then connected the IV tubing to the PICC line access. V10 did not change gloves throughout the entire observation. On 7/23/2025 at 10:43 AM, V10 stated she forgot to put on a gown before she entered R117's room to administer the IV medication. V10 stated she should have worn a gown into R117's room because he is on contact isolation and enhanced barrier isolation. V10 stated she usually puts on gloves when she gets into the room then gathers supplies and prepares supplies for use and does not usually change gloves before she accesses the IV access line. V10 stated she doesn't know what the policy says about when to change her gloves.On 7/24/2025 at 10:09 AM, V2 (Director of Nursing) stated it is the standards of practice to perform hand hygiene between glove changes and she expects hand washing to occur between glove changes. V2 stated she expects the nurse to wear clean gloves when accessing the IV and if the nurse touches anything else prior to accessing the IV line then they should change their gloves and perform hand hygiene right before they access the IV. V2 stated R117 is on contact isolation and enhanced barrier isolation and a gown should be worn by all staff anytime care is being performed so V10 should have worn a gown when administrating the IV medication.A facility policy titled Infection Prevention and Control Manual dated 2019 documents under Policy 3. sterile gloves and examination gloves are removed: d. before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated.An undated facility policy titled Infection prevention and Control Manual-Enhanced Barrier Precautions documents under Policy enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism (MDRO) as well as those at increased risk for MDRO acquisition (such as resident that have wounds or indwelling medical devices). Enhanced barrier precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. In the same policy it documents high-contact resident care activities where a gown and gloves should be used include Caring for or using an indwelling medical device. Event ID: Facility ID: 145256 If continuation sheet Page 6 of 6