Inspection·March 28, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview and record review the facility failed to provide services of a Registered Nurse for eight consecutive hours per day, seven days a week. This has the potential to affect all 38 residents residing at the facility. Findings include: On 3/26/2024 at 9:30am, V1 (Administrator) was asked to provide documentation of the facility having the services of a Registered Nurse, 8 consecutive hours a day, for seven days a week. At around 1:00pm, V1 provided the facility's nurse schedules for the months of January 2024, February 2024 and March 2024. The facility's March 2024, February 2024 and January 2024 Nurses Schedules document only V5, V6, V12 -V20 LPN's (Licensed Practical Nurses) were scheduled to provide patient care during the months provided. There were no RN's (Registered Nurses) documented as working during those three months. On 3/26/2024 at 2:00pm, V6 (LPN) reviewed the March 2024, February 2024 and January 2024 Nurses Schedules and verified all nurses on the schedule (V5, V6, V12-V20) were all LPN's and none of the nurses on the schedule, who had worked, were RN's. V6 said V2 (Director of Nursing/DON) was the only RN who worked at this facility during that time. On 3/26/2024 at 4:10pm, V1 said she did not have a written schedule of the RN's who provided the facility's RN coverage. V1 said instead she would provide the timecard punches as documented proof of the required RN coverage. V1 said V21 (Minimum Data Set Coordinator/RN) and V22 (DON) were employed at a sister facility, and they had provided the Registered Nurse coverage for this facility. V1 provided separate documentation for V2, V21, and V22; and Time Clock Reports for the dates of 3/1/2024 through 3/26/2024. The documents provided for V2 were without title, had separate columns indicating their times clocked in and clocked out, but did not indicate which facility V2 had worked at. The documents for V21 provided the same information and did not indicate which facility V21 had worked at. The documents for V22 also provided the same information and did not indicate which facility V22 had worked at. On 3/28/2024 at 10:31am, V12 (LPN) said the only RN that works at this facility was V2 (DON). On 3/28/2024 at 9:30am, V11 (Regional Director of Operations) said V1 would not be available today because she was working that evening. V11 was asked for the documented proof of the facility's 8 consecutive hours of RN coverage 7 days a week for the period of 1/5/2024 through 3/28/2024. At 10:31am, V11 presented the same timecard punch documentation for V2, V21 and V22 as V1 had provided on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145514 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 03/28/2024 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)