Inspection·December 15, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of the out of town trauma hospital Discharge Summary documented R3 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. Discharge diagnoses are listed as: Fall against object; Trauma; Traumatic fracture of ribs with tiny pneumothorax, left (#3-10), closed, initial encounter. This document stated After observation, he (R3) was tolerating a diet, pain was controlled on oral medications only with stable vital signs and labs. Therefore, (name) R3 was discharged in improved/stable condition. On 12/8/23 at 1:42 PM, R3 was asked if he recalled falling from the lift previously in which he responded yes. When asked if he knew what had happened that caused him to fall, R3 stated no. When asked if he experienced pain when he fell, stated yes. No responses were made when asked to rate his pain on a 0-10 scale. R3 stated yes when asked if he is happy with his care at the facility. On 12/8/23 at 2:29 PM, V10 (CNA) stated that she was a staff member performing the mechanical lift transfer on R3 when he sustained a fall from the lift. V10 stated that R3's cognition level varies as his normal status. V10 stated herself and V11 (CNA) had placed the mechanical lift sling under R3 while he was in bed and connected the sling to the lift and ensured a secure connection. V10 stated once in the air, she is unsure what occurred as it happened so fast but R3 fell from the sling, landing on his left side on the floor over the leg of the mechanical lift. V10 stated after the fall a sling loop was noted to be disconnected from the lift, but she doesn't know how that occurred. V10 stated V4 (Licensed Practical Nurse/LPN) was notified immediately and came to assess R3. V10 stated R3 was expressing no concerns of discomfort at the time, just that he wanted up. V10 stated R3 was sent to the emergency room (ER) for evaluation. V10 stated the sling used with the mechanical lift was inspected with no imperfections noted, as well as the lift being inspected with no faulty equipment noted. V10 stated she had never experienced any problems with the lift or this type of occurrence before. V10 stated she was interviewed by V1 (Administrator) regarding the incident and has been re-trained on mechanical lift use. On 12/8/23 at 4:14 PM, V11 (CNA) confirmed she was the aide transferring R3 with V10 from bed to his chair when he sustained a fall from the mechanical lift. V11 stated she is familiar with R3 and frequently provides his care. V11 stated R3 has trouble expressing his thoughts, with cognition varying as his normal status. V11 stated R3 requires the mechanical lift for transfer. V11 stated she is unsure of the root cause of the fall or any errors that occurred as it happened so fast and connections to the lift were checked prior to transfer. V11 stated while R3 was in the air being moved from the bed to over his chair, somehow a loop of the sling became disconnected from the lift and R3 fell to the floor. V11 stated R3 landed on his left side and herself and V10 did not move R3, but called for V4, who was his nurse. V11 stated V4 immediately responded and R3 was sent to the ER for evaluation. V11 stated R3 was not complaining of any discomfort, just wanted off of the floor. V11 stated she was interviewed by V1 regarding the fall and even after investigating cannot say what the problem was that allowed R3 to fall. V11 stated she has been re-trained in mechanical lift use and there have been no further incidents or falls with mechanical lift transfers. On 12/12/23 at 8:10 AM, V4 (LPN) stated she was the nurse working when R3 sustained a fall from the mechanical lift. V4 stated she was called to R3's room where she observed R3 lying on his left side over the leg of mechanical lift. V4 stated that V10 and V11 were the CNA's present, getting him out of bed and were shocked and couldn't explain what had happened that a portion of the sling had come undone from the lift, in which R3 then fell forward out of the sling and onto the floor. V4 stated that R3 was not complaining of any discomfort at that time and just wanted off the floor. V4 stated R3 was placed back in bed, and she notified the MD who ordered for R3 to go to the ER for eval. V4 stated that the ER eval did detect injuries including rib fractures were sustained. V4 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 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 145514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 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 0689 does not know the root cause of the fall but was re-trained herself on mechanical lift use as a facility wide in service was conducted. Level of Harm - Actual harm Residents Affected - Few On 12/12/23 at 11:28 AM, V2 (Director of Nursing) acknowledged that R3 sustained a fall with fractures from a mechanical lift. V2 stated although the facility was unable to determine the root cause of the fall it is noted that if correct transfer procedures were being implemented, a fall should not have occurred. V2 stated R3 has been receiving pain medication and follow up assessments as indicated following his fall. On 12/8/23 at 9:30 AM, V1 (Administrator) stated that she's had no complaints made to her regarding improper nursing care, RN staffing, or falls. V1 stated she does acknowledge that an error or malfunction of some sort occurred during a mechanical lift transfer of R3 resulting in a fall with injury. V1 stated an investigation was conducted and the root cause could not be determined, therefore all staff were in-serviced on mechanical lift transfers. Review of R3's current Medication Administration Record (MAR) documented at this time R3 remains receiving a Lidocaine HCl External Patch 4 %, Apply to ribs topically one time a day for traumatic fracture of ribs. Remove after 12 hours. This order has a start date of 10/27/23. An additional order with a start date of 10/26/23, upon R3's trauma hospital return is for, Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. The MAR documents multiple doses of this medication were given as needed for pain and was documented as effective for the management of R1's pain management. An undated facility policy titled, (Company Name) stated, (Company Name) wants to ensure that its residents are cared for safely, while maintaining a safe work environment for employees. This infrastructure includes residents and movement equipment, employee training, and a Culture of Safety approach to safety in the work environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 3 of 3