Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Effingham Healthcare & Senior Living during CMS and state inspections, most recent first.
RN coverage was not available for 8 consecutive hours every day, and the facility did not have a full-time DON on staff. The Administrator stated the DON position had been vacant and that every other weekend there was no RN available for the full 8-hour shift. Facility schedules showed multiple days without RN hours, and the facility had 36 residents.
Lack of Planned Meal Alternatives: Staff did not have a planned alternative menu of similar nutritive value at mealtimes. During a meal observation, the cook said residents who disliked the main entrée could only be offered cold cut, egg salad, or PB&J sandwiches after all meals were served. In Resident Council, multiple residents said they lacked variety and wanted alternative choices, and one resident said the menu was not always posted. The Administrator confirmed there was no policy for alternative food selections and no planned meal alternatives at that time.
A facility failed to protect the privacy of two residents during wound care and personal care. One resident with a sacral pressure ulcer and moderate cognitive impairment was exposed while staff treated the wound with the privacy curtain not pulled and the door left open. A second resident with a sacral pressure ulcer and osteomyelitis was also exposed during treatment while a CNA entered without knocking and moved two roommates out of the room, with the resident’s buttocks visible during the procedure.
Failure to report missing resident property as theft. A resident’s family reported that the resident was missing a pair of shoes after the resident was moved to another room, and staff later confirmed that two pairs of shoes had been reported missing, with one pair found and one still missing. The SSD and Administrator acknowledged the issue was discussed and that housekeeping was notified, but no grievance was filed and the matter was not reported to the state agency as abuse-theft, despite facility policy requiring such reports.
The facility failed to complete a PASRR Level 2 screening for a resident after a new diagnosis of brief psychotic disorder was documented. The resident had multiple psychiatric and neurologic diagnoses, moderate cognitive impairment on MDS, and a care plan addressing anti-psychotic use, but the record did not show a new PASRR screening after the psychiatrist started Quetiapine and documented the new diagnosis. The Administrator stated the facility did not obtain the Level 2 screening.
A resident with a C5 spinal cord injury and a sacral pressure ulcer, who was cognitively intact and required substantial to maximal assist with bathing, did not receive showers as scheduled. The resident said delays in changing his shower time contributed to the problem, and the bathing record showed multiple missed or undocumented showers over several weeks. Staff could not explain why the resident was not bathed as scheduled, and the DON/wound nurse found no documentation that he refused care.
Fall interventions were not implemented for a resident with Alzheimer's disease, TIA, moderate cognitive impairment, wheelchair use, and assistance needs for toilet transfer. The care plan listed anti-slip strips by the bed and toilet plus a call don't fall sign, but surveyors observed these measures were not in place, and staff interviews confirmed the interventions were documented on the care plan yet not reflected in the CNA communication binder.
Failure to Follow Standard Infection Control Practices During IV Care: An RN did not maintain aseptic technique while administering IV antibiotics to a resident with multiple serious diagnoses, including handling IV supplies and the access site without proper hand hygiene, glove changes, or clean setup. In a separate event, an LPN entered a resident on contact isolation without gown, gloves, or hand hygiene before disconnecting IV therapy, and another LPN removed a midline catheter and dressing in the hallway without PPE.
A resident with significant mobility limitations and morbid obesity was being transferred from a shower chair to bed using a mechanical lift by an LPN and a CNA. During the transfer, difficulty maneuvering the lift and lack of communication between staff led to the resident's weight becoming unbalanced, causing the lift to tip over. The resident fell and sustained a head laceration requiring staples, with documentation confirming the incident resulted from improper handling during the transfer.
Failure to Maintain a Clean Resident Room: A resident admitted with CVA and MI-related diagnoses had fecal matter smeared on the floor between two beds in the room. Surveyors observed the same fecal matter before and after housekeeping swept and mopped, and the resident later stated the room was not cleaned well or daily. The Administrator stated housekeeping was expected to clean resident rooms per policy, including removing fecal matter from the floor.
Failure to maintain aseptic technique during bowel incontinence and catheter care was observed for a resident with an indwelling catheter, frequent bowel incontinence, moderate cognitive impairment, and a stage 4 sacral wound. Two CNAs provided care without gowns, reused washcloths for multiple passes, did not follow front-to-back technique, contaminated the sacral wound area with dirty gloves, and performed multiple glove changes without hand hygiene. One CNA stated Enhanced Barrier Precautions should have been applied before care began.
The facility did not ensure that an RN was present for at least 8 consecutive hours each day as required, with only partial RN coverage on multiple days and no other RNs available to meet the standard. This affected all 32 residents in the facility, as confirmed by review of schedules and staff interviews.
The facility did not provide 8 hours per day, 7 days per week RN coverage, with multiple days lacking an RN or having the DON work less than the required hours. Both the DON and Administrator confirmed awareness of the staffing shortfall, and 37 residents were present in the facility during this period.
The facility did not consistently offer substantial evening snacks to residents, as required by policy. Several residents reported not being asked if they wanted snacks after dinner, and staff confirmed that snack availability depended on what the kitchen left before closing, often resulting in insufficient or non-nutritious options. This inconsistency affected all residents in the facility.
Surveyors found that multiple residents' rooms and common areas were not maintained in a clean or sanitary condition, with soiled briefs and bed pads left on floors, sticky and visibly soiled surfaces, and black substances present in bathroom sinks and shower room grout. Staff confirmed these conditions did not meet facility standards, and facility policy requires regular cleaning and disinfection.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as evidenced by observations and record reviews.
A resident with a history of urinary retention and frequent UTIs was found with a completely full leg catheter drainage bag, causing urine to back up into the tubing. Despite care plan interventions and physician orders to empty and replace the drainage bag as needed, staff failed to check and drain the bag in a timely manner. An LPN acknowledged the risk of infection due to the full bag, and the deficiency was observed during survey.
The facility did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, as required. On multiple occasions, there was either no RN scheduled or the DON worked less than the required hours, affecting all residents in the facility. The issue was attributed to a recent RN resignation and ongoing recruitment challenges.
A resident with severe cognitive impairment was left in urine-soaked clothing during mealtime, highlighting a failure in providing necessary hygiene assistance. Despite requiring supervision for toileting, the resident was observed with wet clothing and a urine puddle beneath him, which staff did not promptly address. This incident reflects a breach of the resident's rights to dignity and respect.
The facility lacks a full-time Registered Dietitian or Certified Dietary Manager, affecting all 34 residents. The Dietary Manager role has been vacant since June, and a Registered Dietitian visits only monthly. Quality Assurance meetings have not had a Dietary Manager present since June, with the Registered Dietitian providing necessary information.
The facility's kitchen was found to be unsanitary, with dirty equipment, improper food storage, and inadequate hand hygiene practices. Observations included dirty stove burners, uncovered drinks at improper temperatures, and a lack of a cleaning log. The administrator intervened to prevent the serving of potentially contaminated drinks.
The facility failed to provide scheduled weekend activities for residents, despite their preferences for such activities being documented in their MDS assessments. The Activity Director did not schedule weekend activities, leaving it to nursing staff, and the facility's calendar showed no activities on several weekends. The Administrator acknowledged the issue but noted the absence of a formal policy on activities.
The facility failed to prepare meals according to the specified diet orders for several residents, resulting in improper food textures being served. During a lunch observation, the cook did not use liquid in the food processor or perform the necessary consistency tests, leading to some residents receiving incorrect meal textures. Additionally, inconsistencies in pureed food preparation were noted, and the dessert did not match the menu description.
The facility failed to implement proper infection control practices, including enhanced barrier precautions for residents with wounds and indwelling devices. Staff did not disinfect a glucometer between uses, placed soiled linens on the floor, and mishandled an ice cooler lid, all contrary to facility policies.
A facility failed to provide written notification to a resident's representative regarding a hospital transfer. The resident, who was only alert to person and not cognitively intact, was admitted to the hospital due to emesis and inability to keep medication down. The administrator confirmed that notification was given via phone but not in writing.
A facility failed to notify a resident's representative in writing of the bed hold policy during a hospital transfer. The resident, not cognitively intact, was admitted to the hospital with emesis and medication issues. The administrator confirmed that the notification was given via phone but not in writing, and the facility lacked evidence of a bed hold policy.
The facility failed to accurately code MDS assessments for three residents, resulting in discrepancies in their records. One resident's MDS incorrectly documented the absence of a Level II PASRR condition despite having a diagnosis of Bipolar Disorder. Another resident's MDS included an incorrect diagnosis due to an unchecked system error. The third resident's MDS inaccurately indicated no serious mental illness despite having multiple psychiatric diagnoses. These errors were identified through observation, interviews, and record reviews, revealing a lack of thorough verification in the assessment process.
RN Coverage and DON Staffing Deficiency
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was available 7 days a week for 8 consecutive hours a day and failed to ensure a full-time Director of Nursing (DON) was on staff. On 04/26/2026 at 10:40 AM, the Administrator stated the facility had not had a DON since 3/13/26 and that a replacement was being hired, but no start date had been set. In the interim, facility staff were doing the scheduling, and a regional nurse was contacted if questions or concerns arose. On 4/26/2026 at 10:45 AM, the Administrator stated that every other weekend the facility did not have an RN available to work the full 8-hour shift, and that they were seeking to hire an RN who could cover those weekends. Review of the facility schedules for February, March, and April 2026 documented multiple dates lacking RN hours. The facility application dated 4/26/26 documented that 36 residents resided in the facility. The Director of Nursing Services policy stated the nursing services department is under the direct supervision of an RN and that the director is employed full time and is responsible for ensuring sufficient and competent staffing levels.
Lack of Planned Meal Alternatives
Penalty
Summary
The facility failed to provide alternative substitutes of similar nutritive value at mealtimes. During observation of the lunch meal, the meal served was roasted turkey, glazed carrots, and stuffing, and the cook stated there was not a planned meal alternative for residents. The cook explained that if a resident did not like what was served, staff would make a cold cut sandwich, egg salad sandwich, or peanut butter and jelly sandwich after all meals were served out. During the Resident Council meeting, multiple residents stated they did not have a variety of foods to choose from for meals and wanted an alternative option. One resident stated the menu was not always posted on the board, which was the only way residents knew what would be served at the next meal, and said it would be helpful to know ahead of time what the meal and alternative would be. The Administrator stated the facility was working to incorporate an always available menu with a variety of protein and side options, and confirmed there were no planned meal alternatives at that time, only leftovers from previous meals or the sandwich options described by the cook. The Administrator also stated there was no policy regarding alternative food selections.
Failure to Protect Resident Privacy During Wound Care
Penalty
Summary
The facility failed to protect the privacy of 2 residents during wound care and personal care activities. One resident had been admitted with a pressure ulcer of the sacral region and had moderate cognitive impairment per MDS/BIMS. During wound care, the resident was in bed with the blankets pulled back, the incontinence brief loosened, and the lower body exposed when the surveyor entered the room. The roommate was present and appeared to be sleeping. The RN, wound nurse, and CNA removed the brief and treated the pressure ulcer on the resident’s left hip while the privacy curtain was not pulled. During the treatment, two staff members left the room to get supplies, and the door to the hallway was left open while the resident remained exposed. A second resident, also with moderate cognitive impairment and diagnoses including a sacral pressure ulcer and osteomyelitis, was observed receiving treatment to a pressure ulcer on the sacrum while two roommates were present in the room. Although the roommates’ curtains were pulled around their beds, the door to the room was left open at times while staff obtained supplies. During the treatment, a CNA entered without knocking, went behind one roommate’s curtain, assisted that roommate out of the room, then entered the other roommate’s curtain without knocking and assisted her out as well. This occurred while the resident’s buttocks were exposed during the wound treatment. The facility’s dignity policy stated that staff are expected to knock before entering residents’ rooms and to promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Report Missing Resident Property as Theft
Penalty
Summary
The facility failed to report an allegation of a missing resident item to the state agency for 1 resident, R27, who was reviewed for abuse. R27’s care plan meeting record dated 4/9/2026 documented discussion of missing shoes with the wound nurse, MDS coordinator, social services director, and family. On 4/27/2026, the resident’s family member stated she had noticed that R27 was missing a pair of Skechers shoes when she came to the facility a few weeks earlier and had alerted staff. She stated she was still waiting to hear how the facility planned to resolve the missing shoes. Facility staff confirmed that R27 had been moved to a different room and that two pairs of shoes were reported missing, with one pair later found and the other still missing. The social services director stated the issue was discussed at the care plan meeting and that housekeeping was notified to look for the shoes, but she did not file a grievance form or place the matter on the grievance log. The administrator stated she was aware of the missing shoes, that housekeeping was looking for them, and that the facility did not report the matter to the state department as abuse-theft. The facility policy stated that reports of theft or misappropriation of resident property are to be reported to local, state, and federal agencies as required.
PASRR Level 2 Screening Not Completed After New Psychotic Diagnosis
Penalty
Summary
The facility failed to ensure a PASRR Level 2 screening was completed for one resident, R4, after a new diagnosis of brief psychotic disorder was documented. R4’s transfer/discharge report listed diagnoses including bipolar disorder, cerebral infarction, dementia, brief psychosis episode, and major depressive disorder, and the MDS assessment showed a BIMS score of 09, indicating moderate cognitive impairment. The care plan addressed anti-psychotic use for brief psychotic disorder and paranoid delusions related to major depressive disorder, with interventions to administer medications as ordered and consult with pharmacy and the physician as needed. R4’s record included a prior PASRR Level 1 screen outcome stating no Level 2 was required due to no serious mental illness, but after the psychiatrist’s visit and new order for Quetiapine with a new diagnosis of brief psychotic disorder, the record did not document a new screening. The Administrator stated the facility did not obtain a Level 2 screening after the new diagnosis.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure showers were provided as scheduled for one resident who required substantial to maximal assistance with bathing. The resident was admitted with diagnoses including a complete lesion at the C5 level and a pressure ulcer of the sacral region. The resident’s MDS documented a BIMS score of 15, indicating cognitive intactness, and the care plan identified the resident as usually able to perform ADLs with setup to moderate assistance, with an intervention for maximum assist with showering/bathing. The resident stated he had not received a shower for a long time because he requested a day shift shower and it took a long time to make the change, adding that he had only recently started getting showers about three weeks earlier. The facility shower list showed the resident was to receive bathing assistance on Monday, Wednesday, Friday, and Saturday, but the bathing documentation showed multiple dates marked NA or with no initials, indicating bathing was not completed on numerous scheduled days across several date ranges. A CNA stated she had previously come in on days off to assist the resident with showers and that the resident’s showers used to be on night shift, while the wound nurse stated there was no documentation that the resident refused bathing and had no good explanation for why bathing was not provided as scheduled. The administrator stated residents should be assisted with bathing as scheduled.
Fall interventions not implemented as documented
Penalty
Summary
The facility failed to ensure that fall interventions documented in the care plan were implemented for one resident reviewed for falls. The resident had diagnoses including Alzheimer's disease, transient cerebral ischemic attack, major depressive disorder, vitamin D deficiency, and anemia, and the MDS documented moderate cognitive impairment, partial/moderate assistance needed for toilet transfer, and use of a wheelchair. The care plan identified the resident as a fall risk related to not ambulating due to a wound to the left heel and listed interventions including anti-slip strips next to the bed, anti-slip strips in front of the bathroom toilet, and a call don't fall sign in the room. During observation, the resident's room did not have non-skid strips in front of the bed, the bathroom had no anti-slip strips in front of the toilet, and there was no call don't fall sign hanging in the room. Staff interviews showed the CNA stated these interventions were not included in the communication book, while the RN, MDS Coordinator, and Wound Nurse stated the interventions were documented on the care plan and should have been in place. The facility's Care Needs Notices binder had no documentation of the resident's fall interventions, and the Fall-Clinical Protocol stated staff and the physician would monitor and document the resident's response to interventions intended to reduce falling.
Failure to Follow Standard Infection Control Practices During IV Care
Penalty
Summary
The facility failed to ensure standard infection control practices were followed during IV medication administration for a resident with chronic kidney disease stage 3, acute kidney failure, sepsis, a sacral pressure ulcer, weakness, and moderate cognitive impairment. The resident’s record showed he was receiving IV daptomycin for osteomyelitis. During observation, an RN donned a gown and gloves and entered the resident’s room, but placed IV supplies on the bedside table without wiping it down or using a barrier. The RN primed the IV tubing, and the tubing blue cap touched the floor during priming. The RN then handled the tubing and the resident’s clothing and arm with the same gloves used before entering the room, while the saline flush and alcohol wipe remained on the bedside table without a barrier. The RN flushed the IV site and connected the tubing without cleaning the IV access point where the cap had been. When an air alarm sounded, the RN stopped the pump, removed the tubing from the access, and flicked the tubing to remove air while holding the IV connection site with her hand. During this process, the RN did not perform hand hygiene or change gloves. The RN then reached into her scrub pants pocket for keys, used the medication cart, returned to the resident, cleaned the IV site again, and reconnected the tubing without hand hygiene or glove changes. The facility’s administration set/tubing change procedure required hand antisepsis and aseptic non-touch technique when connecting, changing, and accessing administration set injection ports. The facility also failed to follow standard precautions for another resident with a urinary tract infection, contact isolation, moderate cognitive impairment, and an order for IV Zosyn. An LPN entered the resident’s room with a saline flush but did not don a gown or gloves and did not perform hand hygiene before disconnecting the IV tubing and flushing the IV port. Although a contact isolation sign and PPE were posted outside the room, the LPN stated she should have donned a gown and gloves. In a separate event, another LPN removed a resident’s midline catheter and dressing in the hallway without donning a gown or gloves after the catheter had come out earlier that morning. The resident was alert and oriented, and the LPN stated she should have used a glove when removing the catheter and dressing but had delayed doing it until seeing the resident in the hallway.
Unsafe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for mobility due to multiple medical conditions including morbid obesity, chronic systolic heart failure, and osteoarthritis, was being transferred from a shower chair to her bed using a mechanical lift. The resident was cognitively intact and required assistance from one to two staff members for transfers, as documented in her care plan and Minimum Data Set. During the transfer, two staff members, an LPN and a CNA, were involved in operating the mechanical lift and guiding the resident. The incident happened when the staff encountered difficulty maneuvering the mechanical lift, particularly with the wheels, while the resident was elevated in the sling. Both staff members reported that the resident's weight became unbalanced during the transfer, specifically when the CNA repositioned the resident's legs while the lift was still in motion. This caused the mechanical lift to tip over, resulting in the resident falling to the floor and the lift striking her on the head, causing a laceration that required two staples. The resident was sent to the emergency room for evaluation and treatment and returned with orders for staple removal in seven days. Interviews with the staff involved and facility leadership confirmed that there was a lack of communication between the LPN and CNA during the transfer, and the resident's weight was close to the mechanical lift's maximum capacity. The facility's investigation and documentation indicated that the unbalanced weight during repositioning and movement of the lift led to the tip-over and subsequent injury. The facility's policy on mechanical lift use emphasized safe lifting principles but did not substitute for manufacturer training or instructions.
Failure to Maintain a Clean Resident Room
Penalty
Summary
The facility failed to keep resident rooms clean and maintain a safe, clean, comfortable, and homelike environment for one resident in the sample. R5 was admitted on 11/21/2025 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, ST-elevation myocardial infarction of unspecified site, and presence of aortocoronary bypass graft. On 11/22/2025, surveyors observed five separate areas of fecal matter smeared on the floor between bed 1 and bed 2 in R5's room. After observing housekeeping staff clean the room, including sweeping and mopping, the same five areas of fecal matter were still present on the floor. The housekeeping staff member stated she had swept and mopped the room, and the Administrator stated the expectation was for housekeeping staff to clean resident rooms per facility policy, including cleaning fecal matter off the floor. On 11/24/2025, R5 stated the facility does not clean very well and does not clean his room daily, and surveyors again observed fecal matter in the same area between bed 1 and bed 2 still smeared on the floor. The facility policy stated residents are to be provided with a safe, clean, comfortable and homelike environment, including a clean, sanitary, and orderly environment.
Failure to Maintain Aseptic Technique During Incontinence and Catheter Care
Penalty
Summary
The facility failed to maintain aseptic technique during bowel incontinence care and catheter care for a resident who was admitted with diagnoses including urinary tract infection, acute kidney failure, pressure ulcer of the sacral region, and malignant neoplasm of the endocervix. The resident’s MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident was dependent for toileting care. The record also documented an indwelling catheter, frequent bowel incontinence, and a stage 4 pressure wound to the sacrum, with Enhanced Barrier Precautions planned because of the wound. During observation, two CNAs provided bowel incontinence and indwelling catheter care while wearing gloves but not gowns. One CNA used the same washcloth for multiple passes, did not follow front-to-back technique, and placed washcloths on the mechanical lift pad and bed pad while the resident was soiled with bowel movement. The CNA also removed the saturated film covering from the sacral wound and pushed foam back into the wound with dirty gloves. The other CNA used a dirty washcloth to clean the catheter tube and perineal area, also without following front-to-back technique. The CNAs were observed doffing gloves without hand hygiene, leaving the room to get more washcloths, returning and applying new gloves without hand hygiene, and continuing care without changing gloves or performing hand hygiene after dressing the resident and setting up the bed. The CNAs stated they completed perineal care the way they were trained, and one stated she should have applied Enhanced Barrier Precautions before starting care. The DON and Administrator stated their expectation was that staff follow policy and procedure for perineal and bowel incontinence care.
Failure to Provide 8-Hour Consecutive RN Coverage Daily
Penalty
Summary
The facility failed to provide the required services of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as mandated by regulation and the facility's own staffing policy. Review of the nursing schedules for August and September 2025 revealed that on several dates, including 8/9/25, 8/23/25, 8/24/25, 9/6/25, and 9/7/25, there was not an RN present for the required 8 consecutive hours. On these dates, the only RN coverage was provided by one RN who worked only 4 hours each day, and no other RNs were present to fulfill the remaining hours. This was confirmed by both the Administrator and the Director of Nursing during interviews, who acknowledged the lack of continuous RN coverage, particularly on weekends. The facility's resident matrix indicated that 32 residents were living in the facility at the time of the deficiency. The Director of Nursing stated that the facility was aware of the shortfall and attributed it to ongoing efforts to recruit additional RNs. The facility's policy, dated 2001, specifically requires that an RN provide services for at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified dates.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours per day, 7 days per week Registered Nurse (RN) coverage, as documented by the facility's nurse schedules and employee timecard reports. On multiple dates across June, July, and August 2025, there was either no RN scheduled or the scheduled RN, who was also the Director of Nursing (DON), worked less than the required 8 hours. Specific dates were identified where no RN was present, and on several occasions, the DON worked between 3 to 7.5 hours instead of the mandated 8 hours. Interviews with the DON and the Administrator confirmed awareness of the RN coverage shortfall. The DON acknowledged gaps in the schedule and noted that a PRN nurse had recently started to help cover shifts, while the facility continued to advertise for an RN position. At the time of the deficiency, 37 residents were residing in the facility, as documented in the Minimum Data Set (MDS) Resident Matrix.
Failure to Routinely Provide Substantial Evening Snacks
Penalty
Summary
The facility failed to provide substantial evening snacks to residents, as required by their policy and regulatory standards. Multiple alert and oriented residents reported that staff did not routinely offer them snacks after dinner or before bedtime, and that they were not asked if they would like a substantial snack such as a half sandwich or yogurt. Some residents stated that while they could request a snack earlier in the day, staff did not proactively offer snacks in the evening. Staff interviews confirmed that the availability and quantity of evening snacks depended on what the kitchen left before closing, with the kitchen being locked after staff left. Commonly available snacks included oatmeal cream pies, chips, graham crackers, and occasionally yogurt or sandwiches, but there were not always enough snacks for all residents, and substantial snacks were rarely provided. The facility's policy required that evening snacks be routinely offered to all residents and that nourishing snacks from the basic food groups be provided if the time between dinner and breakfast exceeded fourteen hours. However, staff interviews revealed inconsistency in snack provision, with some staff stating that there were sometimes not enough snacks for all residents and that the type of snack varied based on kitchen supply. The lack of routine offering and insufficient quantity and quality of snacks had the potential to affect all 37 residents residing in the facility.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, safe, and sanitary environment for residents. In several resident rooms, soiled briefs and bed pads were found on the floor for extended periods, and sticky or visibly soiled floors were noted. One room had a large area of dried spilled liquid on the floor, and a bathroom sink was found with a black substance and cracks, with the substance extending into and under the cracks. The south hall shower room contained a black substance along the walls and in the grout, with the substance extending several inches up the walls and between tiles. These conditions were directly observed by surveyors during their visits and were confirmed by staff interviews. Facility staff, including maintenance and nursing personnel, acknowledged that the observed conditions did not meet facility standards or expectations. The facility's own policy requires regular cleaning and disinfection of housekeeping and environmental surfaces, including immediate cleaning when surfaces are visibly soiled. Despite these policies, the observed deficiencies affected all residents reviewed for environmental conditions, indicating a failure to consistently implement cleaning protocols and maintain a homelike and sanitary environment.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews, which revealed that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Timely Drain Catheter Bag Increases Infection Risk
Penalty
Summary
A deficiency occurred when staff failed to timely drain a full indwelling catheter bag for a resident with a history of cerebral infarction, urinary retention, neuromuscular bladder dysfunction, and previous urinary tract infections. The resident's care plan included an intervention to empty the drainage bag as needed, and there was an active order to replace the bedside drainage bag with a leg bag each morning. Despite these directives, observation revealed that the resident's leg catheter drainage bag was completely full, with urine backing up into the tubing. A Licensed Practical Nurse confirmed that the bag was so full that urine was backing up, acknowledging that this situation could lead to infection, especially since the resident was known to have frequent urinary tract infections. The CDC guidelines referenced in the report emphasize the importance of regularly emptying catheter bags to prevent infection, but staff failed to check and empty the resident's drainage bag in a timely manner, resulting in the observed deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required by regulation and facility policy. Review of the May and June 2025 nurse schedules and employee timecard reports revealed multiple days where no RN was scheduled or present, and several days where the Director of Nursing (DON) was scheduled as the RN but worked less than the required eight hours. Specifically, on several dates in May and June, there was either no RN coverage or the DON worked between 5.25 and 7.5 hours instead of the mandated eight hours. Interviews with the DON and the Administrator in Training confirmed awareness of the RN staffing shortages, attributing the issue to a recent RN resignation and ongoing recruitment efforts. The facility did not utilize agency staffing to fill these gaps. At the time of the deficiency, 34 residents were residing in the facility, as documented in the Minimum Data Set (MDS) Resident Matrix.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to ensure proper hygiene care for a resident, identified as R31, who was left in urine-soaked clothing during mealtime. R31, who has a diagnosis of schizophrenia and severe cognitive impairment, requires supervision or assistance for toileting hygiene and lower body dressing. Despite these needs, R31 was observed walking to the dining room with wet clothing and subsequently sat in a chair where urine formed a puddle beneath him. Staff members passed by without addressing the situation until a surveyor intervened, highlighting a lack of timely assistance and attention to the resident's dignity. The resident's care plan indicated a need for supervision and assistance with activities of daily living, including maintaining privacy and dignity. However, during the incident, the resident was left in a wet state, and the area was not promptly cleaned, as evidenced by the Director of Nursing using a paper towel to soak up the urine after the resident had returned to the dining room. The resident's guardian expressed concerns about the resident being left in such a condition, expecting staff to maintain the resident's cleanliness and dignity. This incident reflects a failure to uphold the resident's rights to dignity and respect as outlined in the Illinois Long Term Care Ombudsman Program Residents' Rights booklet.
Lack of Full-Time Dietary Management
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a full-time Certified Dietary Manager, which has the potential to affect all 34 residents residing in the facility. On September 17, 2024, a cook stated that there was no one in the Dietary Manager role, as the previous person quit shortly after starting. The facility administrator confirmed on September 20, 2024, that the position has been vacant since June 2024, despite efforts to fill it. Although a Registered Dietitian visits once a month to review residents' nutritional needs, this does not meet the requirement for full-time presence. Additionally, the facility's Quality Assurance monthly meeting records show no attendance by a Dietary Manager since June 2024, with the Registered Dietitian providing necessary information for these meetings.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which has the potential to affect all 34 residents residing in the facility. During an initial tour of the kitchen, several deficiencies were observed, including the absence of paper towels at the hand wash sink, dirty stove top gas burners, and unclean sides of the oven with spilled food and grease. Additionally, the flat top grill's grease/crumb trap was full of old food crumbs and grease, and dried food matter was found under the oven. Non-handle scoops and Styrofoam cups were improperly stored in bulk containers of fortified powder, brown sugar, and sugar. A towel was used to prop open the back door, and a fan with flies and dirt was blowing air into the kitchen, potentially contaminating uncovered drinks. Further observations revealed that glasses of milk, water, and lemonade were left uncovered and not in an ice bath, with the milk temperature recorded at 59 degrees, which was acknowledged as high by the cook. The administrator intervened to prevent the serving of these drinks and instructed the staff to clean the fan. Additionally, it was noted that there was no cleaning log in the kitchen, and a cook was observed handling both dirty and clean dishes without washing hands or using gloves. A cleaning schedule was provided later, indicating a policy for cleaning tasks, but it was not being followed at the time of the survey.
Failure to Schedule Weekend Activities for Residents
Penalty
Summary
The facility failed to provide scheduled daily activities that met the goals and preferences of six residents, as identified during interviews and record reviews. These residents had various diagnoses, including hemiplegia, major depressive disorder, dementia, bipolar disorder, anxiety disorder, chronic obstructive pulmonary disease, and post-traumatic stress disorder. Their Minimum Data Set (MDS) assessments indicated that activities such as reading, listening to music, being around animals, participating in group activities, and going outside for fresh air were important to them. However, during a resident council meeting, these residents reported that no activities were scheduled on weekends, which was a concern for them. The Activity Director, V12, confirmed that no activities were scheduled for weekends, leaving it to the nurses and certified nurse assistants to engage residents. The facility's September 2024 activities calendar corroborated this, showing no activities scheduled on several weekend dates. The Administrator, V1, acknowledged having discussed the need for weekend activities with the Activity Director but noted that the facility lacked a formal policy on activities, instead claiming to follow regulations. This lack of scheduled activities on weekends led to the deficiency identified by the surveyors.
Failure to Prepare Meals According to Diet Orders
Penalty
Summary
The facility failed to prepare food in the proper form according to the diet orders for five residents, leading to a deficiency in meeting the nutritional needs of these residents. During a lunch meal observation, the cook did not prepare the meals according to the specified mechanical soft and pureed diet textures. Specifically, the cook did not use any liquid in the food processor while blending the food, which is necessary to achieve the correct consistency. Additionally, the cook did not perform the required spoon tilt test to ensure the proper food consistency was obtained. As a result, some residents received regular meatloaf instead of the required mechanical soft meatloaf, and one resident was observed coughing while eating. The report also highlights inconsistencies in the preparation of pureed food, with family members noting that the food's consistency varied from being too thin and runny to too thick. The cook admitted to not adding liquid to the pureed or mechanical soft diets, fearing it would make the food too runny, and also forgot to prepare pureed bread for the meal. Furthermore, the dessert served did not match the menu description, as the fruited gelatin did not set properly and was runny. The cook expressed uncertainty about why the gelatin did not set, despite preparing it in advance. A CNA, who previously worked in the kitchen, mentioned that she had trained the cook to use hot liquid to achieve the correct consistency for pureed food items.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement and follow proper infection prevention and control practices for several residents, particularly those with wounds and indwelling medical devices. During an initial tour, it was observed that there were no signs indicating residents were on enhanced barrier precautions, despite the presence of residents with conditions that warranted such measures. The Director of Nursing and the Administrator acknowledged that enhanced barrier precautions had not been implemented, and it was noted that staff had not received comprehensive training on these precautions. Additionally, there were specific instances of non-compliance with infection control protocols. A Licensed Practical Nurse was observed using a glucometer on multiple residents without disinfecting it between uses, contrary to the facility's policy requiring cleaning between each resident to prevent cross-contamination. Another LPN was seen placing soiled linens on the floor during catheter care, which is against the facility's policy, as confirmed by the Administrator. Furthermore, a Certified Nurse Assistant was observed mishandling an ice cooler lid by placing it back on the cooler after it had fallen on the floor, without cleaning it. This action was not in line with the expected infection control procedures. These observations highlight a pattern of inadequate adherence to infection control practices, which could potentially compromise resident safety.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding a hospital transfer. The resident, identified as R3, was admitted to the facility on 7/21/06 and was only alert to person. R3's responsible party was documented as V22, the guardian. On 8/23/24, R3 was transported and admitted to a local hospital due to reddish/brown emesis and an inability to keep medication down. During an interview on 09/19/24, the administrator, V1, stated that the resident and/or their representative were notified of the hospital transfer via phone but confirmed that no written documentation was provided to the resident representative. V1 also noted that R3 was not cognitively intact as their baseline status.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident's representative in writing of the bed hold policy during a transfer to a hospital. The resident, who was only alert to person and not cognitively intact, was admitted to the facility on 7/21/06 and had a guardian as their responsible party. On 8/23/24, the resident was transported to a local hospital due to reddish/brown emesis and an inability to keep medication down. The facility's administrator stated that the resident's representative was informed of the bed hold policy via phone and that the information was sent with the resident, but confirmed that no written documentation was provided. Additionally, the facility could not provide evidence of a policy and procedure for bed holds upon request.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, leading to discrepancies in their records. For one resident, the MDS inaccurately documented the absence of a Level II Preadmission Screening and Resident Review (PASRR) condition despite having a diagnosis of Bipolar Disorder and a Level II PASRR outcome. Another resident's MDS incorrectly included a diagnosis of a psychotic disorder, which was not present, due to an automatic system error that was not double-checked by the MDS Coordinator. The third resident's MDS inaccurately indicated no serious mental illness despite having diagnoses of schizoaffective disorder, borderline personality disorder, and major depressive disorder. These inaccuracies were identified through observation, interviews, and record reviews, highlighting a lack of thorough verification and manual correction of automatically populated data in the MDS. The MDS Coordinator acknowledged the errors and the need for corrections, indicating a lapse in the facility's process for ensuring accurate resident assessments. These deficiencies in the MDS assessments could potentially impact the care and services provided to the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Effingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeland Rehab & Healthcare Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Evergreen Nursing & Rehab Center | 0.9 mi | ★★★★★ | 4 | 0 |
| Lutheran Care Center | 11.3 mi | ★★★★★ | 0 | 0 |
| Heartland Senior Living | 14.7 mi | ★★★★★ | 1 | 0 |
| The Haven Of St. Elmo | 16.6 mi | ★★★★★ | 14 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.