Inspection·December 24, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few and heels on the ground next to her bed and the mechanical lift hit R1 on the top left side of her head causing a laceration. On 12/24/2025 at 10:45 AM, V4 stated and further clarified that there was a lack of communication between her and V3 during R1's transfer. V4 stated, she had repositioned R1's legs too soon during the transfer while lift was still in motion, which caused the mechanical lift to tip over. On 12/23/2025 at 11:46 AM, V2 (Director of Nursing/DON) stated she had been working the day R1 had fallen with the mechanical lift. V2 stated, V3 and V4 notified her that in the process of transferring R1 from a shower chair to her bed via mechanical lift the lift had tipped over with R1 in the sling causing a laceration to the top left side of her head. V2 stated, the investigation determined that R1's weight became unbalanced during the transfer causing the mechanical lift to tip over. On 12/23/2025 at 11:50 AM, V1 (Administrator) stated she had been notified by V2 that V3 and V4 had been in the process of transferring R1 from a shower chair to her bed via mechanical lift and the lift had tipped over with R1 elevated in the sling causing the lift to hit the top left side of R1's head. V1 stated the investigation determined that R1's weight became unbalanced during the transfer during repositioning and motion of lift and caused the mechanical lift to tip over. On 12/23/2025 at 12:05 PM, V5 (Physical Therapy Assistant/PTA) stated, the mechanical lift could tip over if R1's weight had become unbalanced outside the base center of the mechanical lift during transfer. R1's Progress Note dated 11/26/2025 at 5:55 PM documented R1 was transferring with 2 staff members from shower chair to bed. Resident sustained a fall. Laceration noted to left top of head. Resident sent to ER (emergency room) for evaluation and treat. R1's Progress Note dated 11/26/2025 at 6:30 PM documented R1 returned to facility from local hospital in ambulance accompanied. R1 had new orders to remove staples from laceration in 7 days. R1's after visit hospital summary dated 11/26/2025 documented under history of present illness.mechanical lift flipped over, patient landed on her bottom, mechanical lift struck her in the left side of head, laceration to scalp and under physical exam weight of 437 pounds. This same document under laceration repair dated 11/26/2025 at 4:34 PM performed by V15 (emergency room Physician) to the left parietal scalp area, 2.5 centimeters (cm) in length, repair method of 2 staples. The facility's incident investigation report dated 11/26/2025 documented R1 had been in the process of being transferred via mechanical lift by V3 (LPN) and V4 (CNA). R1 had been being pushed toward the bed when the mechanical lift became unbalanced with resident still elevated in sling. R1 did experience a fall and sustained a laceration to the left top of head. Resident was sent to the local emergency room (ER) for evaluation and treatment. Resident returned from the ER with two staples and orders to remove in 7 days. The facility policy titled Lifting Machine, Using a Mechanical Lift (undated) documented under Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. Steps in Procedure 16. Gently support the resident as he or she is moved, but do NOT support any weight. On 12/23/25 at 11:50 AM, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 12/1/25. In attendance - V1, V2, V3, V12 (Regional Director), and V13 (LPN/MDSC - Minimum Data Set Coordinator). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents that are transferred per mechanical lift. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V2 and V15 (ADON) provided in-service to nursing staff on mechanical lift/safe transfers and return demonstration on use of mechanical lift. Completed on 12/1/25. All beds checked and ensured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 2 of 3 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 12/24/2025 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 0689 Level of Harm - Actual harm they are locked. 4. Plan to monitor performance to ensure solutions are sustained: V2 (DON) will complete observations of 3 lift transfers weekly for 6 weeks. Should any concerns be identified, during transfer, V2 will immediately intervene and provide additional education with return demonstrations. The first complete facility audit was completed on 12/1/2025 by V2. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145514 If continuation sheet Page 3 of 3