Inspection·January 17, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm On 1/4/24 at 2:57 PM, V10 (Social Service Director/SSD) stated last week she walked down the hall and R2 was sitting in her chair by the nurse's station. V10 stated she heard V9 tell R2 that she didn't remember saying something but if she did, she was sorry. V10 stated she stopped and talked with R2, and R2 and V9 were joking around so she didn't think there was an allegation to report. V10 stated R2 will usually have a staff member get V10 if R2 has a concern or issue with anything. Residents Affected - Few The facility's undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present During the investigation residents many residents (sic) were interviewed by the QAC (Quality Assurance Committee) to assess their interactions with (V9) and to directly ask if they had witnessed, heard of, or encountered any form of abuse by her .none of them reported a grievance, negative interactions, or reported witnessing or encountering abuse of any form .Staff interviews: V13 (CNA) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN that it was her boyfriend (V12) that called it in, that it had allegedly occurred when he came to the building (bringing a friend of his who was an employee something to drink). When I asked (V13) if she knew about the alleged allegation prior to this, she reported she did not. It was after it was already reported, and the investigation had begun that she was informed of it. When asking (V13) if she was provided any details of what the alleged abuse was, she reported that (V14) did not tell her that. Thus, being unsure of the nature of the allegation. When this alleged incident was originally reported to this writer, (State Survey Agency) nor the resident could pinpoint a time or a [NAME] (day) of when this event occurred. However, after interview with staff an in reviewing the schedule (as it was reported that during this alleged abuse, V14 was not present) the date of the event came to be of 12/23/2023. After further investigation and interviewing those on the shift of 12/23/2023, it came to reasoning that R2 had an issue with her iPad charger. This then leads me to the next set of interviews to portray the night of 12/23/2023. (V9/LPN) was asked to write a statement of the events of her shift on 12/23/2023 regarding (R2) and her iPad charger. This was her statement, (there is no statement attached). (V15), CNA was on shift during the time of the alleged interaction: (V15) asked if he knew of the events surrounding the night of 12/23/2023, he stated he had heard hearsay statements but that he had not witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. (V16), CNA was on shift during the time of the alleged interaction: Staff denied having witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. When asking if she had any encounter surrounding (R2's) charger, she indicated that (R2's) charger broke and that she let (R2) use hers. This writer then asked that if during this time when (R2) was requesting a charger, if (V9) was present. She reported she was at the North Hall Nurses Station (25 feet approx.(approximately) from the location of which (R2) was sitting. This writer then asked (V16) if during this time (V9) made any commentary about (R2's) iPad or the charger, (V16) stated no. When asked if (V9) said any cuss words or derogatory remarks, she stated no (V14/LPN) stated that he in fact did call this in, but she was present in the building at the time of this event. (On 1/16/24 at 2:38 PM, V1 clarified that V14 stated V12 called it in and V14 was not present in the building at the time of the event). Resident (R2) interview: he is the one who told me she said, that that's f**king bullshit, and said she said a bunch of other s**t, but it's been so long ago, and I don't care. (R2) was asked if she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 2 of 30 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 01/17/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few felt threatened or abused or unsafe, she denied. When interviewing (V9), the following was her report she was not sure of any event occurring. When informed of the allegation she stated, I have never cussed at her or any resident. The only recent encounter we had was I walked by her, and she asked, What the f**k did I do to you? I told her I was not sure what she was talking about. And she rolled her eyes at me. I went to (V10/SSD) and informed her of this encounter and asked her if there was a grievance or anything that I didn't know, and she said there wasn't. (V10) and I went back to (R2) and asked her she was talked about, and she said somebody told her that I said she was an impatient bi**h. (V9) reported she did not say any of that. She did say that one point her and (V16) were speaking behind the nurse's station regarding things non work related and she may have used a cuss word, but she was unclear of if she did or not. But that she doesn't recall or would have ever spoke to or about a resident in such regard .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! The text messages from V12 to V1 (Administrator), indicate that V1 was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 3 of 30 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 01/17/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 10:07 AM, V13 (CNA/Certified Nursing Assistant) stated she had been off work for a couple of days and returned to work on 1/6/24. V13 stated she could tell there was a lot of tension, so she asked V14 (LPN) if something happened. V13 stated V14 (LPN) told her something had happened between R2 and V9 (LPN), and a visitor that she knew had called a complaint in to the state agency. V13 stated she didn't work on 12/23/23 and she hadn't witnessed abuse. When asked if she provided care to R2 and if R2 had reported anything to her, V13 stated she knew R2 was upset that weekend (of 12/23/23) because her IPAD wasn't working. V13 stated that is one thing R2 looks forward to and she couldn't use it. V13 stated they tried different chargers, and they weren't helping. On 1/16/24 at 12:29 PM, V14 (LPN) stated she was not working on 12/23/23. V14 stated, V12 (Visitor) told her about an interaction between V9 (LPN) and R2, that he was upset about it, and she told V12 to report it to V1 (Administrator). V14 stated that V12 attempted to contact V1, and she didn't answer so V12 sent V1 a text message. V14 stated that on 1/8/24, V14 had to go to the facility to chart and that V12 went with her. V14 stated when they arrived at the facility, V1 questioned them both asking why they called a complaint to the state agency. V14 stated V12 told V1 they could talk in the office and V1 refused to go to the office with them. V14 stated V1 kept asking why they called state and when V12 told V1 he wasn't going to talk about it there, V1 stormed off towards her office. On 1/16/24 at 3:20 PM, V15 (CNA) stated he worked on 12/23/23. When asked if he witnessed any interaction between V9 and R2 on 12/23/23, V15 stated, Not in particular. V15 denied hearing V9 curse at or around R2. V15 stated R2 did mention to him that she was tired of talking about it. V15 stated R2 told him she was overwhelmed with the amount of people asking her about it. V15 stated R2 told him she was upset with everything and didn't want to talk about it anymore. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation, V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the person who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (on 1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated that V14 (LPN) and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 4 of 30 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 01/17/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm On 1/16/24 at 1:40 PM, this surveyor asked V1 (Administrator) for a list of staff who worked on 12/23/23. The list that was provided to this surveyor included V17 (CNA) and V18 (LPN). When asked if she interviewed V17 and V18 as their interviews are not included in the investigation provided to this surveyor, V1 stated she had a meeting and asked anyone with information to stay and talk with her. V1 stated she didn't realize V17 had worked that day and she wasn't sure how she missed interviewing him. Residents Affected - Few On 1/16/24 at 1:46 PM, V17 (CNA) stated he did work on 12/23/23 but didn't have any knowledge of V9 (LPN) cursing at R2. V17 stated V1 had not interviewed him related to the allegation. On 1/16/24 at 1:55 PM, V18 (LPN) stated he did work on 12/23/23. V18 stated he hadn't witnessed V9 curse at or around residents. V18 stated no one had asked him about the allegation prior to this interview. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V1 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work here. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect, or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Under definitions the policy describes verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy describes mistreatment as, inappropriate treatment or exploitation of a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 5 of 30 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 01/17/2024 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement the facility abuse policy when they neglected to identify an allegation of abuse, and timely and thoroughly investigate an allegation of abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Residents Affected - Few Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present Staff interviews: (V13/CNA-Certified Nursing Assistant) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN that it was her boyfriend (V12/Visitor) that called it in, that it had allegedly occurred when he came to the building (bringing a friend of his who was an employee something to drink). When I asked (V13) if she knew about the alleged allegation prior to this, she reported she did not. It was after it was already reported, and the investigation had begun that she was informed of it. When asking (V13) if she was provided any details of what the alleged abuse was, she reported that (V14) did not tell her that. Thus, being unsure of the nature of the allegation. When this alleged incident was originally reported to this writer, (State Survey Agency) nor the resident could pinpoint a time or a [NAME] (day) of when this event occurred. However, after interview with staff an in reviewing the schedule (as it was reported that during this alleged abuse, (V14) was not present) the date of the event came to be of 12/23/2023. After further investigation and interviewing those on the shift of 12/23/2023, it came to reasoning that (R2) had an issue with her iPad charger. This then leads me to the next set of interviews to portray the night of 12/23/2023. (V9/LPN) was asked to write a statement of the events of her shift on 12/23/2023 regarding R2 and her iPad charger. This was her statement, (there is no statement attached). (V15), CNA (was on shift during the time of the alleged interaction): (V15) asked if he knew of the events surrounding the night of 12/23/2023, he stated he had heard hearsay statements but that he had not witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. (V16), CNA (was on shift during the time of the alleged interaction): Staff denied having witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. When asking if she had any encounter surrounding (R2's) charger, she indicated that (R2's) charger broke and that she let (R2) use hers. This writer then asked that if during this time when (R2) was requesting a charger, if (V9) was present. She reported she was at the North Hall Nurses Station (25 feet approx.(approximately) from the location of which (R2) was sitting. This writer then asked (V16) if during this time (V9) made any commentary about (R2's) iPad or the charger, (V16) stated no. When asked if (V9) said any cuss words or derogatory remarks, she stated no (V14/LPN) stated that he in fact did call this in, but she was present in the building at the time of this event. (On 1/16/24 at 2:38 PM, V1 clarified that V14 stated V12 called it in and V14 was not present in the building at the time of the event). Resident (R2) interview: he is the one who told me she said, that that's f**king bullshit, and said she said a bunch of other s**t, but it's been so long ago, and I don't care. (R2) was asked if she felt threatened or abused or unsafe, she denied. When interviewing (V9), the following was her report she was not sure of any event occurring. When informed of the allegation she stated, I have never cussed at her or any resident. The only recent encounter we had was I walked by her, and she asked, What the f**k did I do to you? I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 6 of 30 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 01/17/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few told her I was not sure what she was talking about. And she rolled her eyes at me. I went to (V10/SSD) and informed her of this encounter and asked her if there was a grievance or anything that I didn't know, and she said there wasn't. (V10) and I went back to (R2) and asked her she was talked about, and she said somebody told her that I said she was an impatient bi**h. (V9) reported she did not say any of that. She did say that one point her and (V16) were speaking behind the nurse's station regarding things non-work related and she may have used a cuss word, but she was unclear of if she did or not. But that she doesn't recall or would have ever spoke to or about a resident in such regard .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage (R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress. R2 stated V9 (LPN) said, this is fu**ing bullsh** and when R2 asked V9 if it was directed at her, V9 didn't respond. R2 stated a different nurse and her husband witnessed the interaction, and R2 believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, upon being informed of a potential allegation of abuse by surveyor, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start an investigation immediately and suspend V9 (LPN). On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 7 of 30 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 01/17/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the one who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated V14 and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 1:40 PM, this surveyor asked V1 (Administrator) for a list of staff who worked on 12/23/23. The list that was provided to this surveyor included V17 (CNA) and V18 (LPN). When asked if V1 interviewed V17 and V18 as their interviews are not included in the investigation provided to this surveyor, V1 stated she had a meeting and asked anyone with information to stay and talk with her. V1 stated she didn't realize V17 had worked that day and she wasn't sure how she missed interviewing him. On 1/16/24 at 1:46 PM, V17 (CNA) stated he did work on 12/23/23 but didn't have any knowledge of V9 (LPN) cursing at R2. V17 stated V1 had not interviewed him related to the allegation. On 1/16/24 at 1:55 PM, V18 (LPN) stated he did work on 12/23/23. V18 stated he hadn't witnessed V9 curse at or around residents. V18 stated no one had asked him about the allegation prior to this interview. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V12 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work here. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 8 of 30 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 01/17/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. Residents Affected - Few 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! This indicates V1 (Administrator) was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. Under definitions the policy describes verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy describes mistreatment as, inappropriate treatment or exploitation of a resident. Under Internal Reporting Requirements and Identification of Allegations the program documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observed, hear about, or suspect to a supervisor and the administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 9 of 30 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 01/17/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation Under Protection of Residents the program documents, The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse, or misappropriation of resident property shall not complete their shift as a direct care provider to residents. Under Internal Investigation of Allegations and Response the program documents, .Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident .Under External Reporting of Potential Abuse, the program documents, 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health Informing Law Enforcement Authorities. If there is clear evidence of abuse by an employee, the Department of Public Health will notify the Health Care Worker Registry or the Department of Financial and Professional Regulation. The Department of Public Health will also notify the State Police for further investigation of the employee. If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours . Event ID: Facility ID: 145514 If continuation sheet Page 10 of 30 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 01/17/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Survey Agency for 1 of 1 (R2) resident reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage(R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress observed. R2 stated V9 (LPN/Licensed Practical Nurse) said, this is fu**ing bullsh** and when R2 asked V9 if it was directed at her V9 didn't respond. R2 stated a different nurse, and her husband witnessed the interaction, and she believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start the investigation immediately and suspend V9 (LPN). A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 11 of 30 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 01/17/2024 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 0609 conversation: Level of Harm - Minimal harm or potential for actual harm 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. Residents Affected - Few 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! This indicates V1 (Administrator) was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the one who reported the allegation. V1 stated V12 came into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 12 of 30 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 01/17/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility with V14 (LPN) (1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated V14 and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA/Certified Nursing Assitant) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V12 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work here. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. V1 stated the allegation was not reported to the local law enforcement since it was an allegation of verbal abuse and not an allegation of physical abuse. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. Under Internal Reporting Requirements and Identification of Allegations the program documents, .Upon learning of the report, the administrator or designee shall initiate an investigation . Under External Reporting of Potential Abuse, the program documents, 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 13 of 30 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 01/17/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Department of Public Health Informing Law Enforcement Authorities .If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 14 of 30 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 01/17/2024 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 0610 Respond appropriately to all alleged violations. 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 timely and thoroughly investigate an allegation of abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 19. Residents Affected - Few Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment phrases and encourage resident to do the same Encourage(R2) to participate in speech consult as needed .Establish eye contact and face resident prior to communication. Assure (R2) you are listening by making eye contact throughout conversation .Use questions that require yes/no answers or one- or two-word responses. Validate responses thru repeating answers . On 1/3/24 at 2:55 PM, R2 was observed in her room with no obvious signs of distress. R2 stated V9 (LPN/Licensed Practical Nurse) said, this is fu**ing bullsh** and when R2 asked V9 if it was directed at her V9 didn't respond. R2 stated a different nurse, and her husband witnessed the interaction, and she believed they reported it. R2 refused to tell this surveyor the name of the nurse who witnessed it. R2 stated there was no physical harm and she wasn't afraid of anyone at the facility. On 1/3/24 at 3:20 PM, upon being informed of a potential allegation of abuse by surveyor, V1 (Administrator) stated she was not aware of any allegation of abuse between V9 (LPN) and R2. V1 stated she would start an investigation immediately and suspend V9 (LPN). On 1/4/24 at 2:03 PM, V9 (LPN) stated she had never cursed or yelled at any of the residents. V9 stated on 12/27/23, R2 told her she was upset with her because V9 yelled at her (R2) on Christmas. V9 stated she explained to R2 that she couldn't have yelled at her on Christmas because V9 didn't work on Christmas. On 1/4/24 at 2:57 PM, V10 (Social Service Director) stated last week she walked down the hall and R2 was sitting in her chair by the nurse's station. V10 stated she heard V9 tell R2 that she didn't remember saying something but if she did, she was sorry. V10 stated she stopped and talked with R2 and R2 and V9 were joking around so she didn't think there was an allegation to report. V10 stated R2 will usually have a staff member get her if she has a concern or issue with anything. The facility's undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 15 of 30 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 01/17/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present During the investigation residents many residents (sic) were interviewed by the QAC (Quality Assurance Committee) to assess their interactions with (V9) and to directly ask if they had witnessed, heard of, or encountered any form of abuse by her .none of them reported a grievance, negative interactions, or reported witnessing or encountering abuse of any form .Staff interviews: V13 (CNA) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN that it was her boyfriend (V12) that called it in, that it had allegedly occurred when he came to the building (bringing a friend of his who was an employee something to drink). When I asked (V13) if she knew about the alleged allegation prior to this, she reported she did not. It was after it was already reported, and the investigation had begun that she was informed of it. When asking (V13) if she was provided any details of what the alleged abuse was, she reported that (V14) did not tell her that. Thus, being unsure of the nature of the allegation. When this alleged incident was originally reported to this writer, (State Survey Agency) nor the resident could pinpoint a time or a [NAME] (day) of when this event occurred. However, after interview with staff an in reviewing the schedule (as it was reported that during this alleged abuse, (V14) was not present) the date of the event came to be of 12/23/2023. After further investigation and interviewing those on the shift of 12/23/2023, it came to reasoning that R2 had an issue with her iPad charger. This then leads me to the next set of interviews to portray the night of 12/23/2023. (V9/LPN) was asked to write a statement of the events of her shift on 12/23/2023 regarding R2 and her iPad charger. This was her statement, (there is no statement attached). (V15), CNA (was on shift during the time of the alleged interaction): (V15) asked if he knew of the events surrounding the night of 12/23/2023, he stated he had heard hearsay statements but that he had not witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. (V16), CNA (was on shift during the time of the alleged interaction): Staff denied having witnessed, encountered, or heard (V9) have a negative interaction or abuse this resident or any resident. When asking if she had any encounter surrounding (R2's) charger, she indicated that (R2's) charger broke and that she let (R2) use hers. This writer then asked that if during this time when (R2) was requesting a charger, if (V9) was present. She reported she was at the North Hall Nurses Station (25 feet approx.(approximately) from the location of which (R2) was sitting. This writer then asked (V16) if during this time (V9) made any commentary about (R2's) iPad or the charger, (V16) stated no. When asked if (V9) said any cuss words or derogatory remarks, she stated no (V14/LPN) stated that he in fact did call this in, but she was present in the building at the time of this event. (On 1/16/24 at 2:38 PM, V1 clarified that V14 stated V12 called it in and V14 was not present in the building at the time of the event). Resident (R2) interview: he is the one who told me she said, that that's f**king bulls**t, and said she said a bunch of other s**t, but it's been so long ago, and I don't care. (R2) was asked if she felt threatened or abused or unsafe, she denied. When interviewing (V9), the following was her report she was not sure of any event occurring. When informed of the allegation she stated, I have never cussed at her or any resident. The only recent encounter we had was I walked by her, and she asked, What the f**k did I do to you? I told her I was not sure what she was talking about. And she rolled her eyes at me. I went to (V10/SSD) and informed her of this encounter and asked her if there was a grievance or anything that I didn't know, and she said there wasn't. (V10) and I went back to (R2) and asked her she was talked about, and she said somebody told her that I said she was an impatient bi**h. (V9) reported she did not say any of that. She did say that one point her and (V16) were speaking behind the nurse's station regarding things non work related and she may have used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 16 of 30 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 01/17/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a cuss word, but she was unclear of if she did or not. But that she doesn't recall or would have ever spoke to or about a resident in such regard .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return to work a shift on 1/6/2023. (V9) was verbally counseled on standard of behavior and these writers' expectations of professionalism regarding the potential (V9) have used profanity in the workplace. A text message thread/exchange between V12 and V1 was reviewed. The phone number in the text thread was noted to be the same phone number provided by V1 (Administrator) and documented the following conversation: 12/23/23 6:52 PM- V12 to V1- Can you call me. It has something to do with the facility and a staff member. 12/26/23 5:43 PM, V12 to V1- I have been trying to get ahold of you about an abuse issue in the facility that's needs reported. Was trying to report it to you rather than state. But it needs reported. 12/26/23 with no time documented, V1 to V12- Who is this? I just saw your message from Saturday. Where I was at Christmas. I've been on PRO PTO (paid time off). V12 responds with his name. V1 responds, Hey (V12)! Sorry about that. Been busy with the holidays. I'm currently in a car full of family. Can I call you as soon as I get to my location to get the details V12 responds, Yes that works. V1 responds, Doing a dinner celebration around 7P, V12 responds, I will be up. 12/27/23 8:47 AM- V1 to V12- I ended up falling asleep!!! I am on the phone will (with) my boss rn (right now) and I will call you as soon as I'm off the conference call. So Sorry! My friend is getting married so last night was busy. There are no further texts until 1/5/23 at 3:11 PM when V12 says, I'm not trying to be a nuisance and cause drama or anything. Just trying to look out for the residents. That facility is their home and should be respected as such. V1 responds with, I appreciate it! The text messages from V12 to V1 (Administrator), indicate that V1 was aware of an allegation of abuse on 12/26/23 and didn't investigate or report the allegation until 1/3/24 when the allegation was reported to V1 by this state surveyor. On 1/8/24 at 1:41 PM, V12 (Visitor) stated he was at the facility on 12/23/23 taking an (unnamed) employee a drink when he witnessed V9 (LPN) cursing at R2. V12 stated R2 had asked V12 to help her plug in her IPAD and V9 got angry and told R2 she was going to f**king wait. V12 stated he attempted to contact V1 (Administrator) on 12/23/23 (Saturday) and V1 didn't answer. V12 stated he called V1 again on Tuesday (didn't specify date). V12 stated V1 didn't answer/respond. V12 stated he then sent V1 a text message on 12/26/23 (which was the Tuesday after Saturday 12/23/23) and told her he had an allegation of abuse to report and V1 didn't respond to the text or call him back for a couple of days. V12 stated when V1 called him, he reported what he had witnessed. V12 stated V1 then called him on Friday, January 5, 2024, and informed him the allegation was being investigated. V12 explained that he had initially reported an anonymous complaint, but reported a second complaint because it seemed nothing was being done and he felt the administrator had lied to the surveyors. V12 stated he knows V9 was at work on Saturday 1/6/24. V12 said he reported the second complaint with his name (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 17 of 30 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 01/17/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attached so he could talk with surveyors about the incident, as he was the one that witnessed V9 cursing at R2 and there were no other witnesses. After explaining that every attempt is made to keep complainants anonymous, but the facility may be able to figure this one out, V12 stated he was ok with them knowing this information. On 1/16/24 at 10:07 AM, V13 (CNA/Certified Nursing Assistant) stated she had been off work for a couple of days and returned to work on 1/6/24. V13 stated she could tell there was a lot of tension, so she asked V14 (LPN) if something happened. V13 stated V14 (LPN) told her something had happened between R2 and V9 and V12 (Visitor) had called a complaint in to the state agency. V13 stated she didn't work on 12/23/23 and she hadn't witnessed abuse. When asked if she provided care to R2 and if R2 had reported anything to her, V13 stated she knew R2 was upset that weekend (of 12/23/23) because her IPAD wasn't working. V13 stated that is one thing R2 looks forward to and she couldn't use it. V13 stated they tried different chargers, and they weren't helping. On 1/16/24 at 12:29 PM, V14 (LPN) stated she was not working on 12/23/23. V14 stated, V12 told her about an interaction between V9 (LPN) and R2 that he was upset about, and she told him to report it to V1 (Administrator). V14 stated, V12 attempted to contact V1, and she didn't answer so he sent V1 a text message. V14 stated on 1/8/24 she had to go to the facility to chart and V12 went with her. V14 stated when they arrived at the facility, V1 wanted to know why they called a complaint to the state agency. V14 stated V12 told V1 they could talk about it in the office and V1 refused to go to the office with them. V14 stated V1 kept asking why they called state and when V12 told V1 he wasn't going to talk about it there V1 stormed off towards her office. On 1/16/24 at 3:20 PM, V15 (CNA) stated he worked on 12/23/23. When asked if he witnessed any interaction between V9 and R2 on 12/23/23, V15 stated, Not in particular. V15 denied hearing V9 curse at or around R2. V15 stated R2 did mention to him that she was tired of talking about it. V15 stated R2 told him she was overwhelmed with the amount of people asking her about it. V15 stated R2 told him she was upset with everything and didn't want to talk about it anymore. On 1/16/24 at 9:48 AM, this surveyor spoke with V1 (Administrator) and informed her there was new information related to the allegation of abuse. When asked about her investigation V1 stated she was able to narrow the date the abuse was to have occurred to 12/23/23. V1 stated it was over an IPAD charger cord. V1 stated she talked with staff and residents and the allegation was not founded. V1 stated she found out V12 (Visitor) was the one who reported the allegation. V1 stated V12 came into the facility with V14 (LPN) (1/8/24) and she asked V12 if he had any concerns or issues since he had called her the day before. V1 stated V12 said it had been resolved. V1 stated she pressed V12 and V14 to find out if there were any allegations of abuse and they didn't report anything to her. V1 stated V14 and V9 (LPN) had issues at a past employer when one of them got the other one fired for abuse. When asked which one was fired for abuse, V1 stated she didn't know. V1 stated, V9 does curse, and the facility did train her on professionalism. On 1/16/24 at 1:40 PM, this surveyor asked V1 (Administrator) for a list of staff who worked on 12/23/23. The list that was provided to this surveyor included V17 (CNA) and V18 (LPN). When asked if she interviewed V17 and V18 as their interviews are not included in the investigation provided to this surveyor, V1 stated she had a meeting and asked anyone with information to stay and talk with her. V1 stated she didn't realize V17 had worked that day and she wasn't sure how she missed interviewing him. On 1/16/24 at 1:46 PM, V17 (CNA) stated he did work on 12/23/23 but didn't have any knowledge of V9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 18 of 30 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 01/17/2024 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 0610 (LPN) cursing at R2. V17 stated V1 had not interviewed him related to the allegation. Level of Harm - Minimal harm or potential for actual harm On 1/16/24 at 1:55 PM, V18 (LPN) stated he did work on 12/23/23. V18 stated he hadn't witnessed V9 curse at or around residents. V18 sated no one had asked him about the allegation prior to this interview. Residents Affected - Few On 1/16/24 at 2:38 PM, V1 (Administrator) stated she was notified by V13 (CNA) on 1/6/24 that V12 (Visitor) was the one who reported the allegation. V1 stated she got a call from V12 on 1/6/24, V12 left a message asking her to return his call, but she didn't call him back. V1 stated she saw V12 at the facility on 1/8/24 and she told him to call the facility if he was not able to reach her. V12 stated she stood in the hall with V12 and had a conversation and he told her V9 said he (V12) doesn't fu**ing work her. V1 stated she spoke with R2 and R2 reported there was no interaction between V9 and V12 and that V9 said this is fu**ing bulls**t. This surveyor told V1 that V12 had shared with this surveyor text messages where he had attempted to contact V1 and report the allegation of abuse on 12/23 and 12/26/23. V1 reviewed the text messages she had received from V12 and stated she wasn't sure how she missed that V12 was attempting to report an abuse allegation. After she reviewed the text messages, V1 stated she wasn't sure if she had called V12. V1 confirmed she closed the investigation on 1/6/24 and allowed V9 to return to work on 1/6/24. When asked how she felt the investigation was complete on 1/6 when she didn't speak with V12 until 1/8/24, V1 stated she spoke with R2 who denied it and every staff who could have witnessed it denied the situation occurred. V1 stated she felt like the safety of R2 was secured since R2 denied having issues with V9. The facility Abuse Prevention Program dated 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by Immediately protecting residents involved in identified reports or possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. Under definitions the policy describes verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy describes mistreatment as, inappropriate treatment or exploitation of a resident. Under Internal Reporting Requirements and Identification of Allegations the program documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observed, hear about, or suspect to a supervisor and the administrator .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation Under Protection of Residents the program documents, The facility will take steps to prevent mistreatment, exploitation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 19 of 30 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 01/17/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete neglect, and abuse of residents and misappropriation of resident property while the investigation is underway Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse, or misappropriation of resident property shall not complete their shift as a direct care provider to residents. Under Internal Investigation of Allegations and Response the program documents, .Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident .Under External Reporting of Potential Abuse, the program documents, 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures Five-day Final Investigation Report. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health Informing Law Enforcement Authorities. If there is clear evidence of abuse by an employee, the Department of Public Health will notify the Health Care Worker Registry or the Department of Financial and Professional Regulation. The Department of Public Health will also notify the State Police for further investigation of the employee. If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours . Event ID: Facility ID: 145514 If continuation sheet Page 20 of 30 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 01/17/2024 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 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an acceptable reason for discharge and failed to allow a resident to return to the facility for 1 (R1) of 3 residents reviewed for transfer/discharge in the sample of 19. This failure resulted in R1 remaining in the emergency room without placement from 12/12/23 to 12/18/23 and being admitted to a hospice room at the hospital due to not having a facility to be discharged to. This failure resulted in R1 having feelings of embarrassment, devastation, abandonment and fear of not knowing what was going to happen to him. Findings Include: R1's admission Record with a print date of 1/4/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include quadriplegia, adjustment disorder with anxiety, adjustment disorder with mixed disturbance of emotions and conduct, spastic hemiplegia, neurogenic bowel, and pressure ulcers. R1's BIMS (Brief Interview for Mental Status) dated 11/03/23 documents a score of 15, which indicates R1 is cognitively intact. R1's MDS (Minimum Data Set) dated 12/12/23 documents under Section G, R1 is dependent on staff for all Activities of Daily Living (ADL's). Under Section I, this same MDS documents a diagnosis of quadriplegia. R1's undated Care Plan documents a Focus area with an initiation date of 11/04/23, Dependent for ADLsUnable to assist/Assists only minimally. Not a candidate for Restorative Programming. Further decline in ability/participation likely due to Quadriplegia. Resident is dependent on 2 assist via Hoyer lift for transfers/ADLs. The interventions documented for this Focus area include, Place in wheelchair for positioning while up and all transport Provide bathing, hygiene, dressing and grooming per Resident's preference as able Provide oral care with am and pm cares Scheduled repositioning program .Transfer Resident using mechanical device of Hoyer and 2 staff members . This same Care Plan documents a Focus area with an initiation date of 11/06/23 of, Resident (R1) is known to display/has history of paranoid thoughts/behaviors and/or open conflict/criticism with others including false accusations. Resident refuses care, then accuses staff of denying him care. Adjustment disorder w (with)/mixed disturbances of emotions and conduct. The interventions documented for this care area include, Administer psychotropic medications as ordered by physician . Allow resident time and opportunity to express feelings, anger, or frustration. Provide empathy and validation of feelings while orienting to reality. Ensure 2 staff members are present for care and services to minimize risk of false accusations Investigate any reality basis and share facts w/resident. Provide reality orientation as possible .Psychotherapy services as needed/desired/tolerated by resident . R1's Progress Notes dated 12/12/23 documents, Res (resident/R1) showing s/s (signs/symptoms) of AMS (altered mental status) with hallucinations and delusions. Res making statements that he fell out of bed. Res is paraplegic and unable to get himself in/out of bed. Res transported to (name of local hospital) via (name of local ambulance service). On 1/2/2024 at 2:16 PM, V3 (Hospital Case Manager) stated R1 was sent to the local hospital for evaluation on 12/12/23. V3 stated R1 was discharged from the hospital and cleared to return to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 21 of 30 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 01/17/2024 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 0622 Level of Harm - Actual harm Residents Affected - Few facility on that same day. V3 stated the facility refused to re-admit R1 to the facility. V3 stated the facility hand-delivered discharge papers to R1 while in the hospital emergency room. V3 stated R1 remained in the hospital emergency room from 12/12/23 to 12/18/23. V3 stated on 12/18/23 they were able to get R1 admitted to their in-house hospice and R1 remained in the hospital in a hospice room. V3 stated they have attempted to find placement for R1 and have been unable to find a facility that will accept him. The facility Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 12/12/23 documents under Federal Proceeding.This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and long-term care facility .the reason for this proposed transfer or discharge is: your welfare and needs cannot be met in this facility, as documented in your clinical record by your physician .the safety of individuals in this facility is endangered .the health of individuals in the facility would otherwise be endangered, as documented by a physician in your clinical record . The notice documents R1 will be relocated to the local hospital and the effective date of the transfer is documented as 12/12/23. The untitled letter signed by V11 (Physician) and attached to the facility discharge date d 12/12/2023 documents, It is in my profession (sic) opinion with collaboration of my colleagues: (R1) is not suitable for residency in (name of facility). He has been non-compliant with his wounds treatment, medication, IV (intravenous) therapy, and physician orders. (R1) has exhibited psychosocial distress to other residents that reside within (name of facility). This included but is not limited to the following: verbal aggression, having to relocate his once roommate to a different room to ensure he was not subjected to this. It is of this facility's duties to protect the safety of all the residents while creating a calm living environment. Due to the sensitivity of the population of those we serve including those who have schizophrenia, developmental delays, trauma/PTSD (post-traumatic stress disorder), dementia/Alzheimer, and other mental health diagnosis where the presentation of his behaviors created adverse effects on these residents. Many interventions were utilized in attempts to resolve (R1) bio-psycho-social needs. An attempt to be assessed by (name of clinical social worker and psychiatric consultants) to aide in assisting him in his mental and emotional needs; however, this was met with refusal, thus unable to provide treatment. (Name of facility) also attempted to send many referrals for this resident to outside agencies, Long-Term Care Facilities, Behavioral Homes, and more; however, being met with denials. His refusal of care impacts his overall well-being, coupled with his underlying mental and behavioral changes impede the ability to provide continuity of care to address his medical needs. R1's regional hospital discharge papers dated 9/16/23, prior to R1's admission to the facility, document, R1 is a .male with a past medical history of quadriplegia due to recent spinal cord injury and glaucoma Had stage 4 decubitus ulcers .Pt (patient/R1) left the hospital AMA (against medical advice) .throughout hospitalization Pt (R1) refused IV, labs, and IVF (intravenous fluids) . This indicates the facility was aware of R1's behaviors of refusal of care prior to admission to the facility. R1's local hospital record with an admission date of 12/12/23 documents the following progress notes. 12/12/23 9:02 AM, Patient (R1) is a .quadriplegic who was sent in from nursing home for shoulder pain. Patient was discharged from the nursing home while patient was in the ER (Emergency Room) due to staff at the nursing home being unable to deal with him. Currently we are looking for placement for the patient . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 22 of 30 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 01/17/2024 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 0622 Level of Harm - Actual harm 12/12/23 1:41 PM, This RN (Registered Nurse) spoke with V2 (Director of Nurses) at (name of facility). Again, let V2 know that patient was up for discharge and clarified with her that they will not be allowing patient to return. Requested documentation of refusal to allow the patient to return be faxed to the ER (Emergency Room), V2 stated they would be happy to fax written documentation of this refusal. Residents Affected - Few 12/12/23 3:59 PM, This patient (R1) has requested to go elsewhere than his current NH (nursing home) facility . 12/12/23 5:13 PM, V1 (Administrator) and V2 (Director of Nurses) from (name of facility) dropped of PT (patient/R1) D/C (discharge) papers and took documenters name as recipient. 12/12/23 6:59 PM, Patient (R1) .male history of quadriplegia presenting from the nursing home for musculoskeletal pain. Patient was sent to the ER by the nursing home and then discharged from the nursing home 12/13/23 1:54 PM, Multiple referrals sent to various nursing homes today 12/13/23 7:32 PM, Briefly, (R1) .is being evaluated for placement. Patient (R1) is a quadriplegic and apparently difficult to manage at NH where he was discharged and will not be accepted back. Case management is working on placement. 12/14/23 3:36 AM, I assumed care of this patient (R1) .Patient has been in this emergency department for nearly 2 full days, awaiting placement. Case management has been seeing the patient. He was discharged from his nursing home. The patient is adamant that he would like to be DNR (do not resuscitate), on hospice, with comfort measures only. He clearly has an infected sacral wound, which I see he was admitted for earlier this month although he declines treatment for this. He continues to decline treatment for this here .The patient understands that refusal of treatment for his infections could lead to worsening condition and possible death . 12/16/2023, I again assumed care of this patient .at 7 PM on 12/14. Patient (R1) is refusing any medical treatment, is desiring to be on hospice, is no longer welcome at his living facility, so case management is working on placement at an alternative facility. 12/18/23 9:45 AM, Reviewed Hospice philosophy and desire for hospice care. Patient (R1) understands his choices and able to decipher benefit vs (versus) burden. He is requesting comfort care. Patient informed all long-term care referrals have been declined. Agreeable to plan for possible transfer to accepting hospice house. On 1/4/24 at 11:29 AM, R1 stated he was not aware he was being discharged from the facility when he went to the emergency room on [DATE]. R1 stated he didn't want to return to the facility because he felt like he would just get revenge care. When asked why he was discharged from the facility R1 stated he thought it was because he called the state agency on the facility. R1 stated when the director (no name given) delivered the discharge papers to the hospital she told him he should never have called the police. R1 stated the hospital is currently looking for other options for him. When asked if there was any harm related to his discharge R1 stated, Absolutely. R1 stated he knew it was revenge. R1 stated he told them (the facility) it was illegal to evict someone for no reason. At 3:03 PM on this same date, when asked how he felt about the involuntary discharge, R1 stated it was devastating and embarrassing. R1 stated he felt abandoned, afraid, and didn't know what was going to happen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 23 of 30 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 01/17/2024 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 0622 to him. Level of Harm - Actual harm On 1/4/24 at 1:58 PM, V8 (CNA) stated R1 was never really rude to her. V8 stated she had witnessed him being rude to other staff. V8 stated she never heard R1 yelling or cursing at other residents and didn't have any residents complain to her about R1's behaviors. Residents Affected - Few On 1/4/24 at 2:03 PM, V9 (LPN) stated R1 was just an unhappy person. V9 stated he wouldn't let her, or several other staff provide care for him. V9 stated R1 called staff names and talked about their personal appearances. V9 stated R1 refused care such as dressing changes and turning and repositioning. When asked if any of R1's behaviors were ever directed at other residents? V9 stated, No. It was mostly towards staff. When asked if she had any other residents complain about R1's behaviors, V9 stated, Not really. On 1/4/24 at 1:33 PM, V5 (CNA) stated R1 preferred V5 to be his caregiver. V5 stated R1 was verbally aggressive with other staff but not with him. When asked if R1 was ever verbally aggressive with other residents V5 stated he didn't think so. When asked if any other residents reported being afraid of R1 or appeared afraid of R1, V5 stated, I wouldn't say so. V5 stated R1 usually got out of bed and came out of his room at least daily. When asked if R1 was verbally aggressive in front of other residents V5 stated, The majority of the time he wasn't. I would say he was just happy to be up and out of his room. On 1/4/24 at 1:40 PM, V6 (CNA) stated she and R1 got along pretty well. V6 stated R1 could be difficult and challenging but she didn't have any issues with R1. V6 stated she never witnessed R1 yelling, cursing, or harming other residents. V6 stated she did have residents complain about R1's screaming and cursing. V6 stated they appeared disgusted but not afraid. When asked what she did to mitigate R1's behaviors, V6 stated she would have conversation with R1 and meet R1's needs as much as possible and report to V1 (Administrator) if she needed assistance. V6 stated R1 never physically harmed anyone. On 1/4/24 at 1:50 PM, V7 (Restorative Aid/CNA) stated she got along with R1. V7 stated R1 didn't have a problem with her. V7 stated she remembered R1 having two roommates at different times. V7 stated one of them was masturbating and R1 yelled at him so they moved the roommate to a different room. V7 stated no other residents have voiced fears or concerns related to R1's behaviors. On 1/4/24 at 2:01 PM, R10 stated he doesn't remember being roommates with R1. R10 stated he was not scared of anyone at the facility and doesn't remember being afraid of or feeling threatened by any other resident. On 1/4/24 at 2:08 PM, R11 stated he had a roommate with R1's name. R11 stated he didn't have any problems with R1. R11 stated he is not afraid of any resident at the facility. R11 stated he has never been scared of another resident since he has lived at the facility and was not aware of any resident having a problem with a peer. On 1/4/24 at 12:20 PM, V4 (LPN) stated R1 was very angry, resisted care, and made false accusations against staff. V4 stated R1 didn't really come out of his room but when he did, he was more social. V4 stated R1 would get upset at night and start screaming at staff and the other residents on his hall would get upset. V4 stated R1's language offended a lot of people. When asked what the facility did to mitigate R1's behaviors, V4 stated she didn't really know. V4 stated she knew the social worker, nurse practitioner, and therapist spent a lot of time in R1's room. V4 stated R1 enjoyed having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 24 of 30 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 01/17/2024 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 0622 Level of Harm - Actual harm Residents Affected - Few certain people to vent to. When asked what she did when R1 was having verbally aggressive behaviors, V4 stated she would let V2 (Director of Nurses) know and write a detailed progress note. V4 stated R1 didn't have many good days. V4 stated she would also utilize social services and the therapist. When asked about distraction, redirection, or activities as interventions, V4 stated R1 wasn't really up for staff redirection. V4 stated she knew R1 enjoyed getting up. V4 stated R1 would refuse to get up a lot but when he did get up you could tell R1 really enjoyed it. When asked if other residents reported or appeared being afraid of R1, V4 stated there was one night that he was screaming and yelling and R4 was upset and tearful. V4 stated R4 didn't say she was afraid, but she appeared afraid. R4's progress note dated 12/12/23 10:31 PM documents, This nurse went to administer res's (R4) 1000 medication. Res stated that she was tired due to being kept up all night by the man across the hall who yells awful things all day and night long. This nurse asked res what the man (R1) says. Res became tearful. Res stated He is always yelling the F word which really upsets me. The way he talks to staff is awful. I feel bad for you guys for having to listen to him talk like that. But it's scary for me too. Especially at night. I just lay here and have to listen to the awful things he screams. Res also stated, You guys (staff) are in there all the time, and that takes you guys away from helping other residents. Admin (V1/Administrator) and DON (V2/Director of Nurses) made aware of res's concerns and statements. R4 was discharged from the facility prior to this survey so was not available for interview. On 1/4/23 at 2:57 PM, V10 (Social Services Director) stated R1 was loud and could be very angry and other residents would hear him and be scared. When asked if other residents reported being scared to her, V10 stated she knew the information was in the resident records. This information was requested from the facility. The facility provided this surveyor with R4's progress note dated 12/12/23. They were unable to provide other reproducible evidence related to peers being afraid of R1. On 1/4/24 at 3:18 PM, V2 (Director of Nursing) stated R1 was sent to the local hospital because he was demanding to be sent. V2 stated they heard he was trying to press criminal charges against staff and staff were upset about how R1 had treated them the night before. V2 stated after talking with their corporate office and medical director they determined it was in everyone's best interest to discharge R1. V2 stated there were no charges that were brought against any staff and the allegations were investigated by the facility and the local police. V2 stated she was not aware of R1 targeting any other residents. V2 stated it was unsettling for residents to lay in bed at night and listen to R1 be so insulting. V2 stated she was only aware of R5 complaining regarding R1's behavior and that was because her room was close to R1's and she was alert and oriented. On 1/04/24 at 11:25 AM, R5 stated she is not scared of any other resident at the facility. R5 denied knowing any other resident that was scared of any resident. R5 stated she has a lot of friends that are residents here. R5 denied any concerns. On 1/4/23 at 3:37 PM, V1 (Administrator) stated on the morning of 12/12/23, R1 requested to be transferred to the local emergency room and to call the police. V1 stated she advised the staff to send R1 out per his request. V1 stated R1 reported to the local hospital he wanted to press charges on facility staff for battery. V1 stated the allegation of abuse was investigated by the facility and local law enforcement and there were no findings, and no charges were filed against any staff. V1 stated they had been reviewing a possible discharge for R1 since they couldn't meet R1's needs. V1 stated hospice had been in and R1 refused hospice services with four different providers. V1 stated they reviewed R1's refusal of care. V1 stated on night shift prior to R1 being transferred to the local (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 25 of 30 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 01/17/2024 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 0622 Level of Harm - Actual harm Residents Affected - Few hospital on [DATE], R1 had been shouting and it was bothering R4. V1 stated after reviewing the information with the interdisciplinary team they came to the conclusion it was better for the psychosocial care of our other residents to discharge R1 from the facility. V1 stated there were only three staff members R1 liked, so medical care was met with resistance from R1. V1 stated R1 told hospice and the local law enforcement on 12/12/23 at the hospital that he didn't want to return to the facility, so that helped make the decision in moving forward with the involuntary discharge. V1 stated R1 was not allowed to return to the facility from the hospital. V1 stated R1 was transferred to the hospital on [DATE] and was given the immediate involuntary discharge papers while at the hospital on [DATE]. V1 stated she knew there were residents who complained about how R1 talked to the staff and him cursing. V1 stated R1 did not yell at other residents. R1 was just vocal and vulgar. When asked if R1 was capable of physically harming someone, V1 stated, No, R1 only had control of his left arm. The undated facility Transfer and Discharge Policy and Procedure documents, It is the policy of (name of corporation) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility .3. The safety of individuals in the facility is endangered In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the resident's welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Type of Transfer and discharge: Less than 30-day notice. Transfers and discharges with less than 30 days' notice may occur in limited circumstances. 1. The health or safety of others in the facility is endangered; 2. The health of the resident has improved to allow more immediate transfer or discharge; 3. The residents urgent medical needs require more immediate transfer; 4. The resident has not resided in the facility for 30 days. Under Involuntary transfers or discharge the policy documents, Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record .In all other instances of involuntary transfer or discharge the mandated federal and state 30 day 'Notice Transfer or Discharge will be issued, and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents' representative and/or the person or agency responsible for the resident's placement, maintenance, and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing including the names of those in attendance. The summary shall be made a part of the resident's clinical record. 3. A physician's discharge order shall be obtained in the residents record prior to discharge. 4. Prior to transfer or discharge the Social Services Director shall counsel the resident and summarize the counseling session in the resident record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 26 of 30 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 01/17/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a resident an advanced written notice of involuntary discharge with appeal rights for 1 (R1) of 3 residents reviewed for discharge in the sample of 19. Findings Include: R1's admission Record with a print date of 1/4/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include quadriplegia, adjustment disorder with anxiety, adjustment disorder with mixed disturbance of emotions and conduct, spastic hemiplegia, neurogenic bowel, and pressure ulcers. R1's BIMS (Brief Interview for Mental Status) dated 11/03/23 documents a score of 15, which indicates R1 is cognitively intact. R1's MDS (Minimum Data Set) dated 12/12/23 documents under Section G, R1 is dependent on staff for all Activities of Daily Living (ADL's). Under Section I, this same MDS documents a diagnosis of quadriplegia. R1's undated Care Plan documents a Focus area with an initiation date of 11/04/23, Dependent for ADLsUnable to assist/Assists only minimally. Not a candidate for Restorative Programming. Further decline in ability/participation likely due to Quadriplegia. Resident is dependent on 2 assist via Hoyer lift for transfers/ADLs. The interventions documented for this Focus area include, Place in wheelchair for positioning while up and all transport Provide bathing, hygiene, dressing and grooming per Resident's preference as able Provide oral care with am and pm cares Scheduled repositioning program .Transfer Resident using mechanical device of Hoyer and 2 staff members . This same Care Plan documents a Focus area with an initiation date of 11/06/23 of, Resident (R1) is known to display/has history of paranoid thoughts/behaviors and/or open conflict/criticism with others including false accusations. Resident refuses care, then accuses staff of denying him care. Adjustment disorder w (with)/mixed disturbances of emotions and conduct. The interventions documented for this care area include, Administer psychotropic medications as ordered by physician . Allow resident time and opportunity to express feelings, anger, or frustration. Provide empathy and validation of feelings while orienting to reality. Ensure 2 staff members are present for care and services to minimize risk of false accusations Investigate any reality basis and share facts w/resident. Provide reality orientation as possible .Psychotherapy services as needed/desired/tolerated by resident . R1's Progress Notes dated 12/12/23 documents, Res (resident/R1) showing s/s (signs/symptoms) of AMS (altered mental status) with hallucinations and delusions. Res making statements that he fell out of bed. Res is paraplegic and unable to get himself in/out of bed. Res transported to (name of local hospital) via (name of local ambulance service). On 1/2/2024 at 2:16 PM, V3 (Hospital Case Manager) stated R1 was sent to the local hospital for evaluation on 12/12/23. V3 stated R1 was discharged from the hospital and cleared to return to the facility on that same day. V3 stated the facility refused to re-admit R1 to the facility. V3 stated the facility hand-delivered discharge papers to R1 while in the hospital emergency room. V3 stated R1 remained in the hospital emergency room from 12/12/23 to 12/18/23. V3 stated on 12/18/23 they were able to get R1 admitted to their in-house hospice and R1 remained in the hospital in a hospice room. V3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 27 of 30 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 01/17/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated they have attempted to find placement for R1 and have been unable to find a facility that will accept him. The facility Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 12/12/23 documents under Federal Proceeding.This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and long-term care facility .the reason for this proposed transfer or discharge is: your welfare and needs cannot be met in this facility, as documented in your clinical record by your physician .the safety of individuals in this facility is endangered .the health of individuals in the facility would otherwise be endangered, as documented by a physician in your clinical record . The notice documents R1 will be relocated to the local hospital and the effective date of the transfer is documented as 12/12/23. R1's local hospital record with an admission date of 12/12/23 documents the following progress notes. 12/12/23 9:02 AM, Patient (R1) is a .quadriplegic who was sent in from nursing home for shoulder pain. Patient was discharged from the nursing home while patient was in the ER (Emergency Room) due to staff at the nursing home being unable to deal with him. Currently we are looking for placement for the patient . 12/12/23 1:41 PM, This RN (Registered Nurse) spoke with V2 (Director of Nurses) at (name of facility). Again, let V2 know that patient was up for discharge and clarified with her that they will not be allowing patient to return. Requested documentation of refusal to allow the patient to return be faxed to the ER, V2 stated they would be happy to fax written documentation of this refusal. 12/12/23 3:59 PM, This patient (R1) has requested to go elsewhere than his current NH (nursing home) facility . 12/12/23 5:13 PM, V1 (Administrator) and V2 (Director of Nurses) from (name of facility) dropped of PT (patient/R1) D/C (discharge) papers and took documenters name as recipient. 12/12/23 6:59 PM, Patient (R1) .male history of quadriplegia presenting from the nursing home for musculoskeletal pain. Patient was sent to the ER by the nursing home and then discharged from the nursing home 12/16/2023, I again assumed care of this patient .at 7 PM on 12/14. Patient (R1) is refusing any medical treatment, is desiring to be on hospice, is no longer welcome at his living facility, so case management is working on placement at an alternative facility. 12/18/23 9:45 AM, Reviewed Hospice philosophy and desire for hospice care. Patient (R1) understands his choices and able to decipher benefit vs (versus) burden. He is requesting comfort care. Patient informed all long-term care referrals have been declined. Agreeable to plan for possible transfer to accepting hospice house. On 1/4/24 at 11:29 AM, R1 stated he was not aware he was being discharged from the facility when he went to the emergency room on [DATE]. R1 stated he didn't want to return to the facility because he felt like he would just get revenge care. When asked why he was discharged from the facility R1 stated he thought it was because he called the state agency on the facility. R1 stated when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 28 of 30 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 01/17/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few director (no name given) delivered the discharge papers to the hospital she told him he should never have called the police. R1 stated the hospital is currently looking for other options for him. When asked if there was any harm related to his discharge R1 stated, Absolutely. R1 stated he knew it was revenge. R1 stated he told them it was illegal to evict someone for no reason. At 3:03 PM on this same date, when asked how he felt about the involuntary discharge, R1 stated it was devastating and embarrassing. R1 stated he felt abandoned, afraid, and didn't know what was going to happen to him. On 1/4/24 at 3:18 PM, V2 (Director of Nursing) stated R1 was sent to the local hospital because he was demanding to be sent. V2 stated they heard he was trying to press criminal charges against staff and staff were upset about how R1 had treated them the night before. V2 stated after talking with their corporate office and medical director they determined it was in everyone's best interest to discharge R1. V2 stated there were no charges that were brought against any staff and the allegations were investigated by the facility and the local police. V2 stated she was not aware of R1 targeting any residents. V2 stated it was unsettling for residents to lay in bed at night and listen to R1 be so insulting. V2 stated she was only aware of R4 complaining regarding R1's behavior and that was because her room was close to R1's and she was alert and oriented. On 1/4/23 at 3:37 PM, V1 (Administrator) stated on the morning of 12/12/23, R1 requested to be transferred to the local emergency room and to call the police. V1 stated she advised the staff to send R1 out per his request. V1 stated R1 reported to the local hospital he wanted to press charges on facility staff for battery. V1 stated the allegation of abuse was investigated by the facility and local law enforcement and there were no findings, and no charges were filed against any staff. V1 stated they had been reviewing a possible discharge for R1 since they couldn't meet R1's needs. V1 stated hospice had been in and R1 refused hospice services with four different providers. V1 stated they reviewed R1's refusal of care. V1 stated on night shift prior to R1 being transferred to the local hospital on [DATE] R1 had been shouting and it was bothering R4. V1 stated after reviewing the information with the interdisciplinary team they came to the conclusion it was better for the psychosocial care of our other residents to discharge R1 from the facility. V1 stated there were only three staff members R1 liked so medical care was met with resistance from R1. V1 stated R1 told hospice and the local law enforcement on 12/12/23 at the hospital that he didn't want to return to the facility, so that helped make the decision in moving forward with the involuntary discharge. V1 stated R1 was not allowed to return to the facility from the hospital. V1 stated R1 was transferred to the hospital on [DATE] and was given the immediate involuntary discharge papers while at the hospital on [DATE]. V1 stated she knew there were residents who complained about how R1 talked to the staff and him cursing. V1 stated R1 did not yell at other residents. R1 was just vocal and vulgar. When asked if R1 was capable of physically harming someone, V1 stated, No, R1 only had control of his left arm. The undated facility Transfer and Discharge Policy and Procedure documents, It is the policy of (name of corporation) not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility .3. The safety of individuals in the facility is endangered In all cases except the last, documentation in the resident's clinical record shall be required. The residents attending physician must document in the resident's clinical record that the facility cannot provide for the resident's welfare, or that the resident no longer requires the facilities services. Documentation in the resident's clinical record by any physician that the health of other individuals would be endangered is cause for transfer or discharge. Type of Transfer and discharge: Less than 30-day notice. Transfers and discharges with less than 30 days' notice may occur in limited circumstances. 1. The health or safety of others in the facility is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 29 of 30 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 01/17/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete endangered; 2. The health of the resident has improved to allow more immediate transfer or discharge; 3. The residents urgent medical needs require more immediate transfer; 4. The resident has not resided in the facility for 30 days. Under Involuntary transfers or discharge the policy documents, Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record .In all other instances of involuntary transfer or discharge the mandated federal and state 30 day 'Notice Transfer or Discharge will be issued, and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents' representative and/or the person or agency responsible for the resident's placement, maintenance, and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing including the names of those in attendance. The summary shall be made a part of the resident's clinical record. 3. A physician's discharge order shall be obtained in the residents record prior to discharge. 4. Prior to transfer or discharge the Social Services Director shall counsel the resident and summarize the counseling session in the resident record. Event ID: Facility ID: 145514 If continuation sheet Page 30 of 30