Inspection·August 15, 2025

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 thoroughly investigate an allegation of abuse for 2 (R1 and R6) of 3 residents reviewed for abuse in the sample of 9.1. R1's admission Record documented an initial admission date to the facility on [DATE] and included diagnoses of hemiplegia affecting left nondominant side, chronic obstructive pulmonary disease, asthma, type 2 diabetes mellitus, morbid obesity, osteoarthritis, obstructive sleep apnea, disorder of prostate, generalized anxiety disorder, major depressive disorder, calculus of ureter, and abdominal pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/01/2025, R1 reported that V4 (Licensed Practical Nurse/LPN) spoke inappropriately to him. V4 was sent home, and investigation immediately initiated.A typed letter dated 08/08/2025 documented it was the follow up to the initial report of a nurse speaking inappropriately to R1. R1 reported that V4 spoke inappropriately to him when he requested his as needed pain medication. V4 explained to R1 that it was not time for his pain medication. R1 reported that this frustrated him. During the investigation, the resident reported that he has a temper and was in pain. The nurse was educated about customer service and approach.The facility's investigation folder provided by V1 (Administrator in Training) included a handwritten letter from R1 that documented R1 turned on his call light at an unknown time. V6 (Certified Nurse Assistant/CNA) answered the call light and went to report (R1's) pain to V4 (LPN). R1 documented that V4 came into his room yelling at R1 saying very loud I guess you want an ambulance too. I was in pain, so I yelled back at him. There was no documentation of this incident in R1's electronic medical record. On 08/12/2025 at 1:02 PM, R1 stated that V4 (LPN) had come in sometime around 8:30 PM and brought R1 medications. R1 said that he fell asleep and woke up 4-5 hours later. R1 stated he turned on the call light and asked V6 (CNA) to ask V4 if it was time for pain medication. R1 stated that V4 said I guess you want a damn ambulance after telling him that it wasn't time for medications. R1 stated that when he woke up, he did not know what time it was. R1 stated that he understands that there is a time frame that has to pass for him to receive his medications. R1 stated that the nurse (V4) was out of line when he yelled at me. R1 stated that he (R1) shouldn't have raised his voice, but he was in severe pain. R1 stated that he had written down what happened on a piece of paper and given the facility a copy of it. On 08/12/202 at 1:19 PM, V1 (Administrator in Training) stated that she was on vacation when this incident occurred between R1 and V4. V1 stated that V11 (Regional Director) completed the investigation. On 08/12/2025 at 1:55 PM, V11 (Regional Director) stated she got a call from V2 (Director of Nursing/DON) regarding the incident that occurred with R1 and V4. V11 stated that she was informed that R1 had upset V4 over pain medication. V11 stated that she did not speak to any of the staff that gave statements. V11 reiterated that R1 stated he was upset and loud. V11 stated that V4 (LPN) has an intellectual issue and does not believe he Residents Affected - Few (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 3 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 08/15/2025 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)