Inspection·May 6, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed to document complete accurate assessments for one resident (R7) of three residents reviewed for documentation in a sample list of eight residents. Residents Affected - Few Findings Include: R7's current diagnoses list includes the following diagnoses: Repeated Falls, Malignant Neoplasm of Prostate, COVID-19, Pain in Unspecified Joint, Abnormalities of Gait and Mobility, Type 2 Diabetes without Complications, Chronic Atrial Fibrillation, Lack of Coordination, Colostomy, Hyperlipidemia, and Vitamin C Deficiency. R7's progress note dated 4/11/25 at 7:30 PM documents R7 was admitted from the hospital emergency room following a fall at the assisted living facility where he lived on 4/11/25. R7's Nursing assessments on 4/11/25 and 4/12/25 do not indicate R7 was having any respiratory symptoms and documents R7 as negative for respiratory signs and symptoms. There are no head-to-toe assessments or respiratory assessments documented on 4/13/25, 4/14/25, or 4/15/25. R7's Electronic Medical record census report documents R7 left for the hospital 4/15/25. R7's progress note dated 4/14/2025 at 11:16 AM documents (R7) Tested positive for Covid; Power of Attorney here and was notified. Stated family member had tested positive and helped resident move in facility. R7's progress note dated 4/14/2025 at 11:33 AM documents Fax sent to (APN) to report covid positive results; chest congestion, cough. R7's progress note dated 4/14/2025 at 11:37 AM Documents Covid isolation precautions initiated. There are no subsequent assessments or notes to indicate where R7 was transferred to or rationale for transfer. There is also no documentation to indicate if the physician or family were made aware of the transfer. On 5/7/25 at 2:00 PM V2, DON (Director of Nursing) stated I am aware our documentation for R7 is lacking and it would be my expectation when a resident becomes symptomatic and tests positive for Covid at very least respiratory assessments should be documented and when a resident is sent to the hospital the reason and an assessment should be documented. (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: 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 05/06/2025 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)