Inspection·October 9, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for a hearing-impaired resident (R73). This failure impacts one of one resident reviewed for impaired hearing in the sample list of 41. Findings include: On 10/07/24 at 10:23 AM R73 observed sitting in his room at the bedside without the television on, looking around. R73 stated I need my hearing aids, I can't hear. On 10/07/24 at 10:25 AM R12 stated R73 cannot hear, and staff must talk loud to him. On 10/07/24 at 10:27 AM V9 and V10 Certified Nursing Assistants stated R73's hearing aid broke a day or 2 after the resident admitted . On 10/08/24 at 11:47 AM V13 Certified Nursing Assistant stated there is a white board at the bedside the staff use to communicate with R73. V13 then shows white board and uses it to communicate with R73 to introduce surveyor to resident. On 10/08/24 at 1:24 PM V14 Care Plan Coordinator confirmed R73's care plan does not address R73's hearing deficit or the use of the white board for communication. V2 Director of Nursing agreed the care plan does not address the hearing deficit or the use of the white board for communication. Undated clinical census page reports R73 was admitted to the facility on [DATE]. R73's Minimum Data Set, dated [DATE], documents R73 has moderate difficulty with hearing. R73's Care plan does not document a hearing assessment or a plan to care for the resident for the hearing impairment. The facility's Care Plan Policy dated 9/20/22 revised on 1/25/24 documents Policy Explanation and Compliance Guidelines: Bullet 1 states the comprehensive care plan will be reviewed and revised an necessary when a resident experiences a status change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 2 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 Based on observation, interview, and record review the facility failed to complete pressure ulcer treatments as ordered and failed to implement pressure relieving interventions for two of two residents (R138, R142) reviewed for pressure ulcers in the sample list of 41. Residents Affected - Few Findings include: 1.) R138's Order Summary dated 10/7/24 documents diagnoses including Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Brain, Secondary Malignant Neoplasm of Bone, Traumatic Subdural Hemorrhage with Loss of Consciousness Status Unknown and Pressure Ulcer of Sacral Region. This Order Summary documents an order dated 9/12/24 for the Unstageable pressure wound due to Necrosis of the Sacrum, cleanse with normal saline, pat dry, apply thin layer of medical honey to the wound bed, cover with a bordered gauze dressing, change daily and as needed. This Order Summary also documents an order for pressure relieving boots to the bilateral lower extremities when in bed to offload pressure, document non-compliance every shift with a start date of 9/12/24. On 10/6/24 at 9:26 AM, R138 was in bed in his room, and he did not have any pressure relieving boots on his feet. On 10/7/24 at 11:58 AM, V4 Registered Nurse and V5 Certified Nursing Assistant prepared R138 for the pressure ulcer treatment. At that time, R138 was lying in bed with no pressure relieving boots on his feet. V4 cleaned the site with normal saline but did not dry the pressure ulcer prior to applying the medical honey as ordered. When V4 applied the medical honey, the honey slid down off the open pressure ulcer partially onto healthy skin. V4 applied the bordered gauze, and the medical honey was not on the open area of the pressure ulcer at that time. On 10/8/24 at 9:39 AM, R138 was lying in bed with his feet pressing up against the foot board and R138 did not have any pressure relieving boots on his feet. On 10/8/24 at 3:01 PM, R138 was lying in bed with no pressure relieving boots on his feet. At that time, V12 Licensed Practical Nurse confirmed that R138 should have the boots on when in bed and confirmed that they were not on R138. V12 stated that they were in the closet. At this time the pressure relieving boots were on the top shelf in the closet. 2.) R142's Order Summary dated 10/7/24 documents diagnoses including Type 2 Diabetes Mellitus, Presence of Cardiac Pacemaker and Small Cell B-Cell Lymphoma. This Order Summary documents an order dated 10/3/24 for the Coccyx wound to cleanse with normal saline or wound cleanser, pat dry, apply thin layer of medical honey, cover with bordered gauze dressing, change daily and as needed. R142's Skin/Wound Note dated 10/3/24 documents R142 was given pressure relieving boots to wear when in bed. On 10/07/24 at 10:07 AM, R142 was lying in bed with her feet directly on the mattress. R142 did not have any pressure relieving boots on her feet. At this time, V4 Registered Nurse and V5 Certified Nursing Assistant prepared to complete R142's pressure ulcer treatment. V4 cleaned the pressure ulcer with normal saline but did not dry the pressure ulcer prior to applying the medical honey as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 3 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 ordered. When V4 applied the medical honey, the honey slid off the pressure ulcer and when V4 applied the bordered dressing the honey was not on the open area of the pressure ulcer. The facility's Pressure Injury Prevention and Management policy with a Reviewed/Revised date of 12/6/23 documents, After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Interventions will be documented in the care plan and communicated to all relevant staff. Event ID: Facility ID: 145031 If continuation sheet Page 4 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to check placement of a Gastrostomy tube (g-tube) prior to administering medications and prior to administering feeding for one of one resident (R138) reviewed for Gastrostomy tubes in the sample list of 41. Findings include: R138's Order Summary dated 10/7/24 documents diagnoses including Unspecified Protein-Calorie Malnutrition, Pneumonitis Due to Inhalation of Food and Vomit, Dysphagia, Metabolic Encephalopathy, Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Brain, Secondary Malignant Neoplasm of Bone and Traumatic Subdural Hemorrhage with Loss of Consciousness Status Unknown. R138's Order Summary dated 10/7/24 documents an order for nothing by mouth with a start date of 9/4/24. This Order Summary documents orders to flush the enteral tube with 30 milliliters of water pre/post medication administration and 5-10 milliliters of water between each medication with a start date of 10/1/24. This Order Summary also documents an order to flush the enteral tube with 125 milliliters of water before and after each bolus feeding with a start date of 9/18/24 and an order for Enteral feeding four times a day of Jevity 1.5 calorie 362 milliliters with a start date of 9/25/24. R138's Order Summary documents orders to check g-tube placement before medications/feedings every shift with a start date of 9/04/2024. On 10/7/24 at 12:10 PM, V4 Registered Nurse prepared R138's Jevity 1.5 feeding and water flushes. V4 unclamped the g-tube and poured in the water flush without first checking placement of the tube. V4 then administered approximately 362 milliliters of Jevity 1.5 and then another water flush. On 10/7/24 at 12:10 PM, when V4 was asked why she did not check placement prior to administering the feeding V4 stated that she checked placement with his earlier feeding this morning. On 10/8/24 at 3:01 PM, V12 Licensed Practical Nurse prepared R138's medications to be administered via Gastrostomy tube without checking placement. V12 administered the water flush, then the Calcium, water flush, Amantadine, water flush, Levetiracetam and then the final water flush. When finished, V12 confirmed that she did not check placement of the Gastrostomy tube prior to administering R138's medications but she should have. The facility's Flushing a Feeding Tube policy with a Reviewed/Revised date of 1/4/24 documents, Prior to flushing the feeding tube, the administration of medication or providing tube feedings, the nurse verifies the proper placement by noting the length of the tubing or performing a measure to check for gastric residual, if performed in the facility. The facility's Medication Administration via Enteral Tube policy with a Reviewed/Revised policy date of 1/4/24 documents, Enteral tube placement must be verified prior to administering any fluids or medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 5 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to permanently affix a narcotic lock box in a medication room for three of three residents (R68, R72, R40), reviewed for medication storage in the sample list of 41. Findings include: 1.) R68's Order Summary dated 10/9/24 documents an order for Morphine Sulfate (Concentrate) Oral Solution 20 mg (milligrams)/ml (milliliters) (Morphine Sulfate), give 0.25 ml by mouth every 6 hours as needed for pain with a start date of 6/2/2024. 2.) R72's Order Summary dated 10/9/24 documents an order for Morphine Sulfate Oral Solution 20 mg/ml give 0.25 ml by mouth every 6 hours as needed for pain, SOB (shortness of breath) with a start date of 7/03/2024. 3.) R40's Order Summary dated 10/9/24 documents an order for Morphine Sulfate ER (extended release) Oral Tablet 15 mg, give 1 tablet by mouth every 12 hours for pain with a start date of 8/26/2024. 4.) R40's Order Summary dated 10/9/24 documents an order for Hydrocodone/Acetaminophen 5/325 mg oral tablet, give 1 tablet by mouth every 8 hours as needed for Pain - Severe with a start date of 2/23/2024. On 10/9/24 at 9:55 AM, V17 Licensed Practical Nurse completed the medication storage room tour and confirmed there was a locked storage box sitting on the shelving unit in the medication storage room and V17 stated that there were narcotics stored in there because she does not have enough room for them in her medication cart lock box. V17 confirmed the lock box is not affixed to anything, just loose on the shelf. V17 opened the lock box and there were three boxes of morphine and three cards of Hydrocodone/Acetaminophen in the lock box. The Morphine labels documented they were for R68, R72 and R40. The three cards of Hydrocodone/Acetaminophen were all for R40 totaling 90 tablets. On 10/9/24 at 11:30 AM, V1 Administrator stated that he gave the nurses that lock box for the extra medications. The facility's Medication Storage policy with a Reviewed/Revised date of 12/20/23 documents, Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 6 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 prevent the potential for cross-contamination of ice, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food service equipment (sink) and floor areas. These failures have the potential to affect all 87 residents residing in the facility. Findings include: 1. On 10/6/2024 at 8:53AM, dark colored mildew growth was located inside of the dietary service ice machine along multiple sections of the plastic evaporator skirt. On 10/8/2024 at 2:10PM, V15 (Regional Dietary Manager) was present and reported the facility maintenance department was responsible for cleaning the machine. 2. On 10/6/2024 at 8:40AM, the kitchen three-basin sink sewer pipe was continuously dripping into a metal pan located on the floor below the sink. The pan was one-fourth full of discolored and opaque water. On 10/8/2024 at 1:31PM, the pipe leak and pan remained the same as above. 3. On 10/6/2024 at 8:41AM, the flooring surfaces throughout the dish line area of the kitchen were sticky and soiled with accumulations of food debris, discarded rubber gloves, dish scrub pads, steel wool pads, pieces of foam, and condiment packets. On 10/8/2024 at 1:33PM, the floors remained as above. V15 was present and stated right (the floors were soiled and need cleaned). 4. On 10/6/2024 at 8:41AM, a can opener mounted to a food prep table near the three-basin sink was soiled with food debris. A second can opener mounted to a food prep table near the kitchen coolers was also soiled with accumulations of food debris and metal shavings. The metal shavings easily fell off the opener when lightly touched. On 10/8/2024 at 1:34PM, the can openers remained the same as above. V15 was present and reported the facility was going to replace the opener located on the prep table near the kitchen coolers. 5. On 10/6/2024 at 8:45AM, the kitchen pantry floor areas were soiled with debris including plastic cup lids, cardboard, plastic wrap, leaves, and foil. On 10/8/2024 at 1:35PM, the soiled floor areas remained as above. The facility Long-Term Care Facility Application for Medicare and Medicaid (10/6/2024) documents 87 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 7 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect three residents (R83, R137, R187) of five reviewed for arbitration agreements on the sample list of 48. Residents Affected - Some Findings include: On 10/9/2024 at 12:06 PM, V3 (Social Services Director) reported R83, R137, and R187 all signed arbitration agreements upon admission to the facility. The facility arbitration agreements signed by R83 on 8/16/2024, R137 on 9/29/2024, and R187 on 8/30/2024 do not include any language providing for the selection of an arbitration venue convenient to both parties. The contract documents the arbitration will occur in the county where the facility is located unless the parties mutually agree otherwise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 8 of 9 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 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 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 Based on observation, interview, and record review the facility failed to place a resident in Enhanced Barrier Precautions for one of 24 residents (R142) reviewed for infection control in the sample list of 41. Residents Affected - Few Findings include: R142's Nurses Note dated 10/3/24 documents R142 has a pressure ulcer on R142's Coccyx with Serosanguineous drainage. On 10/6/24 at 2:35 PM, R142 was in her room and there was no Enhanced Barrier Precaution (EBP) sign posted on her door or near her door. On 10/7/24 at 10:07 AM, V4 Registered Nurse and V5 Certified Nursing Assistant entered R142's room to complete the pressure ulcer dressing change. V4 and V5 did not don a gown prior to completing the dressing change. V4 and V5 had to open R142's incontinence brief to complete the treatment and R142's pressure ulcer was open and greater than a stage 1 pressure ulcer. On 10/7/24 at 10:47 AM, R142's room does not have an EBP sign on the door and there is no indication that staff should don PPE prior to providing care. On 10/8/24 at 12:47 PM, V19 Infection Preventionist confirmed that residents with pressure ulcers should be placed in Enhanced Barrier Precautions. On 10/8/24 at 2:14 PM, V19 stated that R142's pressure ulcer is not chronic so she did not place her on Enhanced Barrier Precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 9 of 9