Inspection·July 15, 2025

F 0584 surfaces are visibly soiled. 6. 6. Floor mopping solution will be replaced every three resident rooms, or changed no less often than at 60- minute intervals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the doctor and obtain treatment orders when a change to a pressure area was detected and failed to apply heel protectors to prevent further skin breakdown for 3 of 4 residents (R3, R4, R5) reviewed for pressure areas in the sample of 27.Findings include:1. R4's admission record documents an admission date of 11/25/2015 with the following diagnoses in part; multiple sclerosis, chronic pain syndrome and autonomic neuropathy in diseases not elsewhere classified. R4's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 7, indicating R4 is severely cognitively impaired. Section M-Skin Conditions documents that R4 has pressure ulcers.R4's Order Summary Report documents R4 has treatment orders to her left ischial tuberosity, Right heel, right medial lower leg, right calf and behind her left knee.R4's Treatment orders on for her right heel document; Right medical heel: Apply barrier wipe q (every) shift and PRN (as needed) everyday shift for DTPI (Deep Tissue Pressure Injury) with a start date of 7/4/25 and a discontinue date of 7/9/25.R4's Treatment Administration Record for July documents that R4 received this treatment every day from 7/4-7/9, 2025. On 7/9/25 at 1:05pm, wound care was observed on R4 and administered by V4 (Licensed Practical Nurse/LPN) and assisted by R3 (LPN). V4 went to apply the barrier wipe to R4's right medial heel, there was a boarder dressing on the right heel dated 7/7. Upon removal of the dressing on R4's heel by V4, the dressing was noted to have a dark bloody tinged drainage on it. R4's right heel was noted to have a small open area approximately 2cmx2cm that was draining. V4 checked the order to ensure she had read it correctly. V4 confirmed it was only the barrier wipe ordered and left the dressing intact. V4 went to notify the Nurse Practitioner and to receive new treatment orders.R4's progress notes document on 7/9/25 at 2:35pm, Floor nurse reported a decline in wound on right medial heel. (Name of wound care provider) NP (Nurse Practitioner contacted, new order received as follows: Cleanse wound with wound cleanser, apply collagen to wound bed, cover with bordered gauze dressing q2d (every 2 days) and PRN (as needed). Order Processed. On 7/9/25 at 1:23pm, V4 stated that the nurse practitioner should have been notified and new orders received when the area was noticed and before any new treatment was applied. 2. R3's admission record documents an admission date of 4/28/25, with the following diagnoses listed in part; adult failure to thrive and muscle weakness.R3's Current Care Plan documents R3 has severe impaired cognitive function or impaired thought processes as evidenced by a BIMS score of 3 related to Dementia, date initiated 5/12/25.R3's Order summary sheet documents an order with a start date of 5/29/25, Heel protectors to be worn in bed every shift for pressure injury.R3's Treatment Administration Record for July, with a print date of 7/9/25 documents an order for heel protectors on while in bed, nursing staff documented that treatment was in place every day from July 1-9, 2025.On 7/7/25 at 1:52pm R3 was observed in bed, without heel protectors on.On 7/8/25 at 1:02pm, R3 was observed lying in bed without heal protectors on and there were no heal protectors anywhere in her room.On 7/9/25 at 9:35am, R3 was observed lying in bed without heel protectors on, V5 did not even have heel protectors anywhere around her.On 7/9/25 at 1:39pm, V3 and V4 both stated they were not sure if R3 should have had heel protectors on while lying in bed. V3 and V4 stated if R3 had an order for them, they should be put on her while she is in bed.On 7/10/25 at 1:41pm, V5 (Certified Nursing Assistant/CNA) stated she was not sure where V3's heel protectors were, but she would locate a pair for her.3. R5's admission record documents an admission date of 3/10/22 with the following diagnoses in part; Type 2 diabetes Mellitus without complications, pressure ulcer of other site, stage 3, and other specified disorders of muscle.R5's Minimum Data Set (MDS) dated [DATE] documents no brief interview for mental status was conducted due to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident is rarely/never understood.R5's Order Summary Report documents the following order, Heel protectors while in bed-Monitor wearing q (every) shift. Ensure heel protectors are on while in bed. With a start date of 5/31/25.R5's Treatment Administration Record for July, with a print date of 7/9/25 documents an order for heel protectors on while in bed, nursing staff documented that treatment was in place everyday from July 1-9, 2025.On 7/7/25 at 1:52pm R5 was observed in bed, without heel protectors on.On 7/8/25 at 1:02pm, R5 was observed lying in bed with her heal protectors laying on her bedside table.On 7/9/25 at 9:35am, R5 were observed lying in bed without heel protectors on.On 7/9/25 at 1:38pm, R5 was observed in bed, and did not have heel protectors in place, they were sitting on her bedside table. V# (LPN) grabbed them and put them on R5.On 7/9/25 at 1:39pm, V3 and V4 both stated that R5 should have had heel protectors on while lying in bed.On 7/9/25 at 2:15pm, V2 (Director of Nursing) stated all treatments performed must have an order, if a treatment is to be changed, the doctor would need to be contacted for further instruction.Facility Policy titled Wound Care with a revision date of October 2010 documents under the section titled, preparation; Verify that there is a physician's order for this procedure. Event ID: Facility ID: 145514 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely drain a full indwelling catheter bag, increasing the resident's risk for infection for 1 of 3 (R2) residents reviewed for catheters in the sample of 27.Findings Include:R2's admission record documents an admission date of 6/12/17 with the following diagnoses listed in part; cerebral infarction, retention of urine, neuromuscular dysfunction of bladder and urinary tract infection, site unspecified.R2's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) was not completed due to resident is rarely/never understood.R2's Order Summary Report documents an active order to replace bedside drainage bag with leg bag each morning.R2's care plan documents resident has an indwelling catheter. resident will show no s/sx (signs and symptoms) of Urinary infection. with interventions including empty the drainage bag when needed.On 7/9/25 at 1:42pm, R2's leg catheter drainage bag was observed to be completely full, and urine was backing up into tubing.On 7/9/25 at 1:43pm, V3 (licensed Practical Nurse) stated that R2's leg bag was so full of urine that it was backing up into the tubing, and that was a good way to get an infection. V3 stated R2 gets frequent Urinary Tract Infections and staff should be checking her drainage bag often since she has a leg bag to ensure it doesn't get so full.Per CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html Section III Proper Techniques for Urinary Catheter Maintenance documents Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. Event ID: Facility ID: 145514 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide substantial evening snacks to residents. This failure has the potential to affect all 37 residents residing at the facility. Findings include:Facility matrix dated 7/7/25 documents there are currently 37 residents living in the facility. On 07/10/25 at 9:30 AM the sign posted on the snack cart documents: breakfast 8:00 AM, lunch 12:00 PM, and dinner 5:00 PM.On 07/10/25 at 10:20 AM, R6 Who is alert and oriented, stated, the staff do not come and ask between after dinner and before bedtime if he would like a snack or a substantial snack such as a half a sandwich or a yogurt. On 07/10/25 at 11:40 AM, R8 who is alert and oriented, stated the staff do not come and ask if she would like a snack in the evening, after dinner. On 07/10/25 at 12:46 PM, R27 who is alert and oriented, stated, they (the staff) do not ask if he would like a snack after dinner in the evening time, but it would be nice if they did. On 07/10/25 at 12:49 PM, R22 who is alert and oriented, stated, the staff do not ask if he would like a snack after dinner in the evening. On 07/10/25 at 12:54 PM, R19 who is alert and oriented, stated, they do not come around and ask if he would like a snack in the evening but if he asks earlier in the day they will bring him a [NAME] bar or something similar.On 07/10/25 at 1:05 PM, R4 who is alert and oriented, stated, she does not remember anyone asking her if she would like a snack in the evening. On 07/14/25 at 11:50 AM, V7 (Minimum Data Set Coordinator) stated, breakfast is at 8:00 AM, lunch is at 12:00 PM, and dinner is at 5:00 PM. On 07/14/25 at 11:13 AM, V9 (Certified Nurse Aide/CNA) stated, sometimes they have snacks for the evening, sometimes not very many. V9 stated the amount of snacks they have depends on how many snacks the kitchen leaves for them before they leave. The kitchen is locked after the kitchen staff leaves. Sometimes they do not have enough snacks for all the residents. The snacks are usually oatmeal cream pies or maybe a plastic bag of chips. V9 stated, very rarely do they have sandwiches or anything like that. On 07/14/25 at 12:08 PM, V13 (CNA) stated, they have some snacks in the evening, depending on how many snacks the kitchen leaves them. The usual snacks are chips, graham crackers, or sometimes yogurt. V13 stated, they do not always have enough snacks for all the residents.On 07/14/25 at 12:11 PM, V14 (CNA) stated, she works every other weekend in the evening. V14 stated, she usually has snacks for the evening, usually oatmeal cream pies or graham crackers and sporadically a half a sandwich. On 07/14/25 at 12:15 PM, V16 (Cook) stated, he will leave snacks for the evening before he leaves. He leaves whatever they have sometimes oatmeal pies, chips, or cookies. V16 stated, sometimes he will put out some sandwiches if they already have some made. The facility policy dated 07/2017 titled, Frequency of Meals documents 6. evening snacks will be offered routinely to all residents. Timing of the snack will consider relevant factors. 7. residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen (14) hours. Nourishing snacks are items from the basic food groups, offered either separately or with each other. Event ID: Facility ID: 145514 If continuation sheet Page 6 of 6