Inspection·March 10, 2025

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the timeliness of laboratory services as ordered by a physician for one (R4) of one resident reviewed for laboratory services on the sample list of three. Residents Affected - Few Findings include: The After Visit Summary (AVS) dated 7/25/24 documents R4 was diagnosed with a kidney stone. The same AVS documents that on 7/19/24 R4 was admitted to the hospital and underwent bilateral Percutaneous nephrolithotomy (PCNL) for removal of bilateral staghorn kidney stones. The same AVS documents that on 7/25/24 at 12:18 PM R4 was discharged from the hospital and returned to the facility. On 7/25/24 Discharge Instructions were printed and document an Inpatient AVS (After Visit Summary) was (Printed 7/25/2024). The AVS documents a 48-hour urine is to be collected two weeks after the operative procedure and sent to the laboratory under the discharge instructions. Two weeks postoperative is August 2, 2024, for the 48-hour urine collection date to start. The AVS also documents instructions for the facility to collect a urine culture in one month and then monthly for two more months. R4's Medical Record documents on 8/4/25 at 5:19 PM a physician order was entered for a urinalysis with culture and sensitivity one-month post-hospitalization, and then monthly for two months with results to the urologist. R4's Medical Record does not document completion of the urine tests and no urine laboratory results were located in the Medical Record. Progress Notes dated 9/11/24 at 9:48 am document the 48-hour urine collection was initiated at 5:00am and will be completed on 9/13/24. The Progress Note dated 9/13/24 at 09:50 AM documents completion of the 48-hour urine. On 3/10/25 at 1:45 PM V2 Director of Nursing confirmed the After Visit Summary dated 7/25/24 contained discharge instructions to obtain 48-hour urine test two weeks post-operatively. On 3/10/25 at 1:50 PM V2 confirmed there are no urine test results (urinalysis/culture and sensitivity) in the medical record. The Laboratory Services and Reporting policy Date Implemented: 01/20/20 documents: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse (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 2 Event ID: 145031 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 03/10/2025 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)