Inspection·September 20, 2024

F 0550 Level of Harm - Actual harm Residents Affected - Few At 12:05 PM, surveyor brought to the attention of V5 (Certified Nurse Assistant/CNA) that R31 was standing up in a puddle and his pants were falling down. V5 at this time took R31 back to his room to clean him up. The chair and floor remained wet during this time. At 12:20 PM, R31 re-entered the dining room in clean dry clothes and sat down in the wet seat with his feet in the puddle of urine under the table. At 12:25PM, V2 (Director of Nursing/DON) placed a paper towel on the floor and used her foot to soak up the puddle asking who spilled something. On 9/18/24 at 2:30 PM, V5 stated that R31 is generally incontinent of urine and bowel and wears an incontinent brief. V5 stated that she did not call housekeeping to clean up the chair or the floor, but she did not see the puddle under the chair. V5 stated that the weight of R31's saturated incontinent brief is what was causing his pants to fall down. On 9/18/24 at 4:30 PM, V10 (Guardian) stated that she visits her residents every quarter. V10 stated that she was last there in June 2024 and when she arrived, R31 was sitting in the common area and his clothing was wet from urine. V10 stated that once she arrived, R31 was taken to be cleaned up and changed. V10 stated that she expects that staff will keep R31 cleaned up, dry and not left sitting in urine-soaked clothing. V10 stated that while R31 is unable to tell us himself, R31 would be embarrassed to be sitting in urine-soaked clothing and a puddle of urine underneath him along with the two other residents sitting next to him at the dining room table. The Illinois Long Term Care Ombudsman Program Residents' Rights for people in Long Term Care Facilities booklet documents that 'Your rights to dignity and respect include: you have the right to make your own choices, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life, and your facility must provide equal access to quality care regardless of diagnosis, condition or payment source. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 2 of 17 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 09/20/2024 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 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 1 (R3) of 1 resident reviewed for hospitalizations in a sample of 24. Residents Affected - Few Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day, along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident and/or their representative were notified of the hospital transfer and/or admission via phone. V1 confirmed that documentation is not provided to the resident representative in writing. V1 stated R3 is not cognitively intact as their baseline status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 3 of 17 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 09/20/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R3) of 1 resident reviewed for notice of bed hold policy upon transfer in the sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident representative was notified of the bed hold policy via phone and sent with the resident. V1 confirmed documentation was not provided to the resident representative in writing. V1 stated R3 is not cognitively intact as their baseline status. The facility did not provide evidence of a policy and procedure for bed holds upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 4 of 17 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 09/20/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R8's admission Record documented an admission date of 11/25/15 and included the following diagnoses: schizoaffective disorder, borderline personality disorder, and major depressive disorder. Residents Affected - Few R8's annual MDS dated [DATE] Section A 1500 completed by V13 documented an answer of No to the question: Is the resident currently considered by the State Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition? This same document in section I5700 documented that R8 has an anxiety disorder, depression, and schizophrenia. R8's medical record included documentation of R8 receiving a Level I and II OBRA (Omnibus Budget Reconciliation Act) screen from a previous facility completed on 12/26/08, which noted that R8 was suitable for long term care placement and required no special services. Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 3 (R8, R9, and R21) of 12 residents reviewed for accuracy of assessments in the sample of 24. Findings Include: 1. R9's admission Record documented an initial admission date of 08/02/2024. Diagnoses listed on this document include chronic obstructive pulmonary disease, cerebrovascular disease, spastic hemiplegia, chronic kidney disease, sleep apnea, unspecified dementia, gastro-esophageal reflux disease, bipolar disease, anxiety, and retention of urine. R9's Notice of PASRR Level II Outcome dated 07/22/2022 documented that You have a Level II PASRR Condition of Bipolar Disorder Level II Outcome: Level II - Approved No SS. R9's MDS with an Assessment Reference Date of 10/12/2013 documented this MDS as being an annual assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asks Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability .or a related condition? The answer was documented as a 0 for No. This same MDS in Section I Active Diagnoses has a checkmark under Psychiatric/Mood Disorder with an X marked for I5900 Bipolar Disorder, indicating this is an active diagnosis for R9. On 09/19/2024 at 11:03 A.M. V13 stated she is not sure why Section A1500 is coded as a No. V13 stated she is aware that R9 has a diagnosis of Bipolar Disorder and a Level II PASARR. V13 stated that she will complete a correction MDS. 2. R21's admission Record documented an initial admission date of 07/21/2021. Diagnoses listed on this document include chronic obstructive pulmonary disease, depression, delusional disorders, unspecified dementia, alcohol abuse with alcohol induced psychotic disorders with delusions, anxiety, and cardiomyopathy. R21's Notice of PASARR Level 1 Screen with a date of 08/01/2023, documented No Level II Required. R21's MDS with an Assessment Reference Date of 07/01/2024 documented this MDS as being an annual assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asks Is the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 5 of 17 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 09/20/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability .or a related condition? The answer was documented as a 0 for No. This same MDS in Section I Active Diagnoses has a checkmark under Psychiatric/Mood Disorder with an X marked for I5950 Psychotic Disorder, indicating this is an active diagnosis for R21. On 09/19/2024 at 10:32 AM, V13 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated that she was not sure why the MDS was coded that way. V13 stated that she double checks the diagnosis list. On 09/19/2024 at 10:58 AM, V13 stated that the system automatically pulls the diagnosis list and puts them in the MDS Section I. V13 stated that she did not double check the list and should have unclicked Section I5950 Psychotic disorder (other than schizophrenia) and changed the yes to a no. V13 stated that R21 has no delusions and that this is inaccurate. V13 stated she will complete a correction MDS. On 09/19/2024 at 11:30 AM, V13 stated that the MDS had been corrected and resubmitted for R21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 6 of 17 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 09/20/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide scheduled daily activities that met resident goals and preferences for six (R2, R3, R7, R12, R30 and R34) of six residents reviewed for activities in the sample of 24. Residents Affected - Some Findings Include: 1. R2's admission Record documented an admission date of 3/1/24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, and multiple sclerosis. R2's Minimum Data Set (MDS) assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people and doing favorite activities was somewhat important to R2, and going outside for fresh air when weather is good was very important to R2. 2. R3's admission Record documented an admission date of 7/21/2006 with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, muscle weakness and bipolar disorder. R3's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices was all somewhat important to R3. 3. R7's admission Record documented an admission date of 5/8/2010 with diagnoses that included bipolar disorder, unspecified, anxiety disorder unspecified and obesity. R7's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines was somewhat important to R7, and listening to music, being around animals, doing things with groups of people, doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices was very important to R7. 4. R12's admission Record documented an admission date of 9/22/2022 with diagnoses that included major depressive disorder, anxiety disorder and cerebral infarction. R12's MDS assessment dated [DATE] under Interview for Activity Preferences documented that keeping up with the news, going outside for fresh air when weather is good and participating in religious services or practices was somewhat important to R12, and having books, newspapers, magazines, listening to music, being around animals, doing things with groups of people, and doing favorite activities was very important to R12. 5. R30's admission Record documented an admission date of 3/10/2023 with diagnoses that included chronic obstructive pulmonary disease, unspecified, dysphagia, oropharyngeal, and muscle weakness. R30's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices was all somewhat important to R30. 6. R34's admission Record documented an admission date of 7/13/2024 with diagnoses that included depression, muscle weakness and post-traumatic stress disorder. R34's MDS assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 7 of 17 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 09/20/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to music, being around animals, keeping up with the news, and doing things with groups of people are somewhat important to R34, and doing favorite activities, going outside for fresh air when weather is good and participating in religious services or practices are very important to R34. On 9/18/2024 at 10:24 AM during the resident council meeting, R2, R3, R7, R12, R30 and R34 were all alert and oriented to time and place. When asked about daily activities, R2, R3, R7, R12, R30 and R34 all stated, there are no activities scheduled on the weekends and all stated they would like to have activities scheduled over weekends. On 9/17/24 at 1:55 PM, V12 (Activity Director) stated she does not schedule any resident activities for the weekend. V12 stated, she leaves that up to the nurses and certified nurse assistants to have activities for the residents. On 9/19/2024 at 9:47 AM, V1 (Administrator) stated multiple times she has discussed scheduling and documenting resident activities for the weekend staff to complete with V12 (Activity Director). V1 stated, the facility does not have a policy on activities, that the facility follows the regulations. The facility's September 2024 activities calendar shows no activities scheduled for 9/1/2024, 9/6/2024, 9/8/2024, 9/13/2024, 9/14/2024, 9/15/2024, 9/21/2024, 9/22/2024, 9/27/2024, 9/28/2024 and 9/29/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 8 of 17 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 09/20/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to have a full time Registered Dietitian or full time Certified Dietary Manager on staff. This has the potential to affect all 34 residents residing in the facility. Residents Affected - Many The Findings Include: On 9/17/24 on 9:00 AM, V4 (Cook) stated that they currently do not have anyone in the Dietary Manager role in the kitchen. V4 stated that there was someone, but they quit a couple days after she started. On 9/20/24 at 2:00 PM, V1 (Administrator) stated that she has not had anyone in the dietary manager role in the kitchen since June of 2024. V1 further stated that she is trying to find someone to fill that role but has not had any luck. V1 stated that they do have a Registered Dietitian come in once a month to review resident nutritional needs, but not full time. Review of the facility's Quality Assurance monthly meeting sign in sheets does not show a Dietary Manager attending the meetings since June (2024). On 9/20/24 at 2:00 PM, V1 stated that the Registered Dietitian provides the necessary information for the quality assurance meeting. The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/17/24, documents 34 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 9 of 17 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 09/20/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to prepare food in the proper form of the diet order for 5 of 5 (R1, R16, R18, R19 and R30) residents reviewed for menus meeting resident needs in the sample of 24. The Findings Include: 1. R1's current order summary report lists diet order as: regular diet, pureed texture. 2. R16's current order summary report lists diet order as: regular diet, pureed texture. 3. R18's current order summary report lists diet order as: regular diet, mechanical soft texture. 4. R19's current order summary report lists diet order as: regular diet, mechanical soft texture. 5. R30's current order summary report lists diet order as: regular diet, mechanical soft texture. On 9/17/24 at 12:00 PM, during lunch meal observation, V4 (Cook) was preparing the altered diets for residents on mechanical soft and puree. V4 stated that she did not have to prepare the meal any different for the mechanical soft diets because it was meat loaf. V4 then pureed the meat loaf, spinach and Au Gratin potatoes and did not use any liquid in the food processor while blending the food. V4 did not use a spoon tilt test to determine if the proper food consistency was obtained for the mechanical soft and puree food items. The menu for 9/17/24 was listed as: Meatloaf, Au Gratin Potatoes, Club Spinach, Bread/Margarine, and a Fresh Fruit Cup on the Week 2 spreadsheet for menus. On 9/17/24 at 12:45PM, the staff were starting to pass trays and R1, R18, and R30 received regular meatloaf at the lunch meal service prior to V1 (Administrator) stopping the tray line to make sure that Mechanical Soft residents received mechanical soft meatloaf. At this time, it was observed that R30 was coughing while eating, but did not choke. The recipe for mechanical soft meatloaf includes the following directions: 1. Place prepared meatloaf into the processor and pulse until lump particles the size of 4 mm(millimeters). 2. Prepare gravy mix and add to the minced meatloaf to add moisture and bind. 3. Minced and Moist foods must pass the IDDSI (The International Dysphagia Diet Standardization Initiative) Fork Test and IDDSI Spoon tilt test. The recipe for the puree meatloaf includes the following directions: 1. Measure out pureed portions required for the recipe. 2. Add to food processor and process to a fine consistency. 3. Prepare broth by dissolving soup base in hot boiling water. 4. Combine hot broth and commercial thickener. Gradually add to meat while processing. All liquid may not be required. 5. Scrape down sides of processor and process for additional 30 seconds. The recipe for puree club spinach includes the following directions: 1. Measure out pureed portions required for the recipe (omit bacon). 2. Add to food processor and process to a fine consistency. 3. Add liquid and thickener and process until smooth. All liquid may not be needed for recipe. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 10 of 17 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 09/20/2024 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 0803 Scrape down sides of processor with a rubber spatula and process for additional 30 seconds. Level of Harm - Minimal harm or potential for actual harm The recipe for Au Gratin potatoes includes the following directions: 1. Measure out pureed portions required for the recipe. 2. Add to food processor and process to a fine consistency. 3. Add liquid and process until smooth. All liquid may not be needed for recipe. 4. Heat to serving temperature. Residents Affected - Some On 9/17/2024 at 11:08 AM, V23 (Family) stated that the pureed food needs some help. V23 stated that the pureed food is not consistent, some days the food is very thin and runny and other days it is too thick. On 9/17/24 at 1:00 PM, V4 confirmed that she did not chop or grind the meatloaf until V1 (Administrator) told her to, and that she did not have gravy prepared for the meal. V4 stated that she doesn't add liquid to the puree or mechanical soft diets because it may make it too runny, so that was why for the puree food items she didn't add any liquid to the food in the food processor. V4 also stated that she forgot to make the pureed bread for that meal, so no puree diets got the bread/margarine. On 9/19/24 at 1:00 PM, the lunch dessert was observed to be fruit in a red liquid served in a bowl. The menu for the day listed the dessert as fruited gelatin. At this time, R8 who is alert to person, place and time stated that she isn't sure what the dessert is, but it looks like canned fruit in red juice. On 9/19/24 at 1:30PM, V4 stated that she is unsure why the fruited gelatin did not set and was runny because she made it two days in advance to ensure that the gelatin would not be liquid. On 9/19/24 at 2:00 PM, V6 (Certified Nurse Assistant/CNA) stated that she was previously a kitchen employee and trained V4 on how to puree, and she taught her to always use a hot liquid to puree the food items to get it to the correct consistency. A Diet Type Report provided by V1 on 9/20/24 at 2:00 PM, lists R18, R19, and R30 as receiving a Mechanical Soft diet. This same report lists R1 and R16 as receiving a puree diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 11 of 17 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 09/20/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 34 residents residing in the facility. The Findings Include: During the initial tour of the kitchen on 9/17/24 at 9:20 AM, the following observations were made: -No paper towels were available at the hand wash sink -Stove top gas burners were dirty with burnt, dried up, and spilled food items on them -The sides of the oven were dirty with spilled food and grease down each side -The flat top grill on the stovetop grease/crumb trap was full of old food crumbs and grease -The floor around the oven had dried food matter under the oven -A non-handle scoop/Styrofoam cups were found in fortified powder, brown sugar and sugar bulk containers -A towel was stuck in the back door to keep it open On 9/17/24 at 12:15PM, a fan was observed sitting in the kitchen window with a screen blowing air into the kitchen from the outside. The fan had flies and dirt on the kitchen side of it, blowing onto drinks to be served at lunch that were not on ice/not covered. On 9/17/24 at 12:35PM, a cart was observed sitting near the serving line with glasses of milk, water and lemonade. The glasses were not covered and were not in an ice bath. V3 (Cook) was asked at this time to take the temperature of the uncovered glass of milk sitting on a kitchen cart. The temperature was found to be 59 degrees. V3 stated that he thought that was a little high on temperature, but they needed to start serving because they were late so there wasn't anything he could do about it. On 9/17/24 at 12:40 PM, V1 (Administrator) came in and told kitchen staff they could not serve the drinks and that they had to be dumped out and new drinks poured. At this same time, V1 stated that they will get the fan cleaned so as to not blow debris potentially onto the food. On 9/17/24 at 2:00 PM, V4 (Cook) stated there is no cleaning log in the kitchen currently. On 9/18/24 at 12:00 PM, V3 (Cook) was observed handling dirty and clean dishes without hand washing or using gloves. A cleaning schedule with a revision date of 10/14 was provided by V1 on 9/19/24. It states that it is the policy of (Long Term Care Facility) to provide a system for determining frequency and cleaning and to document the completion of a particular cleaning task. 1. The Food Services manager shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 12 of 17 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 09/20/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete develop a cleaning rotation form that lists all cleaning tasks required for proper sanitation of the food preparation and serving areas. 2. Tasks are divided into categories that must be completed daily, weekly, and monthly. 3. Each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency. The Long Term Care Applications for Medicare and Medicaid provided by the facility on 9/17/24, documents 34 residents reside in the facility. Event ID: Facility ID: 145514 If continuation sheet Page 13 of 17 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 09/20/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. On 9/19/2024 at 10:45 AM, V8 (Certified Nurse Assistant/CNA) was observed passing ice to residents in their rooms across the hall from the facility conference room. V8 dropped the lid to the ice cooler on the floor, picked the cooler lid up and placed the cooler lid back on the cooler. V8 continued to pass ice to residents in their room. V8 stated she did drop the lid to the cooler on the floor and placed in back on the cooler without cleaning it. Residents Affected - Some On 9/19/2024 at 10:52 AM, V1 (Administrator) stated she would expect V8 not to use the cooler lid after it hit the floor and to follow policy and procedure for infection control. On 9/20/2024 at 11:48 AM, V2 (DON) stated she would expect for staff to follow policy and procedure for infection control and not return a lid back on the cooler that fell on the floor while passing ice to the residents. Based on interview, observation, and record review, the facility failed to follow Infection Control practices for 9 of 12 residents (R1, R2, R4, R6, R8, R9, R11, R12, and R17) reviewed for infection control in the sample of 24. The Findings Include: 1. On the initial tour of the facility on 09/17/2024 beginning at 9:30 AM, there were no resident rooms observed in the facility with signage on the doors indicating residents were on enhanced barrier precautions. On 09/17/2024 a Matrix for Providers (form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On 09/18/2024 at 08:30 AM, during screening of residents, there were no resident rooms observed in the facility with signage on the doors indicating residents were on isolation or enhanced barrier precautions. On 09/18/2024 at 11:01 AM, V2 (Director of Nursing/DON) stated that there is no one currently on isolation. V2 stated that Enhanced Barrier Precautions are for residents with wounds and catheters. V2 stated the facility has no open wounds, so no one is on Enhanced Barrier precautions. V2 stated residents with catheters are not being isolated because they are not growing anything in their urine. On 09/18/2024 at 11:06 AM, V1 (Administrator) stated that all staff know to wear PPE (Personal Protective Equipment) when providing care to residents with wounds and catheters. V1 stated no one is currently on isolation for Enhanced Barrier Precautions. On 09/19/2024 at 9:00 AM, V1 stated the facility has not implemented Enhanced Barrier Precautions yet. V1 stated the regional nurse is coming today to assist V2 in implementing Enhanced Barrier Precautions. On 9/19/2024 at 2:00 PM, V16 (Licensed Practical Nurse) stated that Enhanced Barrier Precautions were new, and the facility just implemented them this afternoon. On 09/20/2024 at 10:45 AM, V2 stated she has talked to staff that have been working but has not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 14 of 17 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 09/20/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some done an all staff in-service yet. V2 stated she put education in the care binder for staff to read. V2 stated she will do an in person all staff education on 09/25/2024. R1's admission Record documented an Initial admission Date of 05/21/2005 and included the following diagnoses: cerebral infarction, chronic kidney disease, bradycardia, hemiplegia, obstructive sleep apnea, gastro-esophageal reflux disease, unspecified dementia, epilepsy, chronic obstructive pulmonary disease and schizoaffective disorder. R1's Order Summary Report dated 09/19/2024 documented an active order to monitor output and color of BIL (bilateral) nephrostomy urine tube everyday shift and night shift. The same document also documented an order for suprapubic urinary catheter change monthly and as needed. R2's admission Record documented an Initial admission Date of 03/01/2024 and included the following diagnoses: hemiplegia, unspecified atrial fibrillation, type 2 diabetes mellitus, multiple sclerosis, obstructive sleep apnea, hyperlipidemia and essential hypertension. R2's Order Summary Report dated 09/19/2024 documented an active order for suprapubic catheter 18 F / 30 ml (18 French with 30 milliliter) bulb change every 28 days and as needed. R4's admission Record documented an admission Date of 07/31/2024 and included the following diagnoses: chronic obstructive pulmonary disease, cellulitis of lower limb, iron deficiency anemia, hypothyroidism, hyperlipidemia, anxiety, bipolar disease, type 2 diabetes mellitus, and acute kidney failure. R4's Order Summary Report dated 09/20/2024 documented an active treatment order for right posterior thigh; right post lateral leg, cleanse area with normal saline, apply collagen to wound bed, apply barrier wipe to peri-wound then hydrocolloid every 3 days and as needed. R6's admission Record documented an Initial admission Date of 01/22/2024 and included the following diagnoses: chronic respiratory failure, gastro-esophageal reflux disease, anemia, hypokalemia, essential hypertension, type 2 diabetes mellitus, neuromuscular dysfunction of bladder and heart failure. R4's Order Summary Report dated 09/19/2024 documented an active order for urinary catheter 16 F / 30 ml (16 French with 30 milliliter) bulb change monthly and as needed. R8's admission Record documented an Initial admission Date of 11/25/2015 and included the following diagnoses: multiple sclerosis, schizoaffective disorder, pressure ulcer of left buttock stage three, gastro-esophageal reflux disease, anxiety, major depressive disorder, hypothyroidism, and chronic obstructive pulmonary disease. R4's Order Summary Report dated 09/19/2024 documented an active order for left ischial tuberosity, cleanse with normal saline, apply barrier wipe to peri wound, apply collagen to wound bed, cover with dressing every three days and as needed. R9's admission Record documented an Initial admission Record of 08/02/2018 and included the following diagnoses: chronic obstructive pulmonary disease, cerebrovascular disease, spastic hemiplegia, chronic kidney disease, sleep apnea, unspecified dementia, gastro-esophageal reflux disease, bipolar disease, anxiety and retention of urine. R9's Order Summary Report dated 09/19/2024 documented an active order for suprapubic 20 F / 30 (20 French with 30 milliliter) bulb to be changed monthly and as needed. R11's admission Record documented an Initial admission Record of 04/01/2024 and included the following diagnoses: major depressive disorder, chronic kidney disease, anemia in chronic kidney disease, type 2 diabetes mellitus, essential hypertension, chronic kidney disease stage 4, end stage renal disease, peripheral vascular disease, and dependence on renal dialysis. R11's Order Summary Report dated 09/19/2024 documented an active order for dialysis site - HD (hemodialysis) tunneled double right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 15 of 17 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 09/20/2024 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 0880 jugular venous access. Level of Harm - Minimal harm or potential for actual harm R12's admission Record documented an Initial admission Date of 09/22/2022 and included the following diagnoses: major depressive disorder, anxiety, hypothyroidism, chronic combined systolic and diastolic heart failure, chronic obstructive pulmonary disease, hyperlipidemia, gout, and disorder of the kidney and ureter. R12's Order Summary Report with a date of 09/19/2024 documented an active order for urinary catheter 16 F / 20 ml bulb, change every month and as needed. Residents Affected - Some R17's admission Record documented an Initial admission Date of 06/24/2022 and included the following diagnoses: cerebral infarction, essential hypertension, type 2 diabetes mellitus, bipolar disorder, retention of urine, and atherosclerosis of coronary artery bypass graft. R17's Order Summary Report with a date of 09/19/2024 documented an active order for urinary catheter, 18 F / 30 ml bulb, change monthly and as needed. A facility provided document labeled Enhanced Barrier Precautions with a date of 07/13/2023, documented Enhanced Barrier Precautions should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, and infection or colonized with a MDRO (Multidrug-Resistant Organisms). Enhanced Barrier Precautions require the use of a gown, and gloves during high - contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. According to https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Under the heading Implementation documents: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 2. On 09/17/2024 at 11:45 AM, V14 (Licensed Practical Nurse/LPN) completed a blood glucose check on a R6. V14 pulled the test strip out of the glucometer and discarded it with her gloves. V14 then sat the glucometer on top of her medication cart. At 12:08 PM, V14 completed another blood glucose test on R4 using the same glucometer. V14 did not clean the blood glucose machine in between resident use. On 09/20/2024 at 12:26 PM, V2 (DON) stated that she would expect the nursing staff to disinfect the blood glucose testing machine in between each resident use. The facility policy titled Cleaning and Disinfecting of Glucometer with an updated date of 12/07/2018 documented Policy: The blood glucose meters will be cleaned between each resident test to avoid cross contamination issues. Under the section titled procedure: 1. Cleaning and disinfecting with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 16 of 17 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 09/20/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Bleach Disposable Wipe will be completed each time the blood glucose meter is used with a pre-moistened towelette. 3. On 09/19/2024 at 2:54 PM, V11 (LPN) provided catheter care to R9. The area around R9's suprapubic catheter was cleaned, and a new dressing applied. V11 cleaned R9's coccyx area and removed sheet from bed, placed it on the floor, then placed dirty wash cloth on the sheet on the floor. V11 stated she forgot a trash bag. V11 then completed R9's treatment to coccyx. On 09/19/2024 at 3:10 PM, V1 stated that she would expect staff to have a trash bag or to throw the washcloths in the trash can. V1 stated it was not the facility policy to place linens on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 17 of 17