Health inspection·July 29, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician's orders for administration of eye drops for one of three residents (R3) reviewed for hygiene in the sample list of 15 residents.On 7/24/25 at 9:18 AM R3 was sitting in a wheelchair. R3's eyes were red with a small amount of yellow/white matter on the lower lids. R3 rubbed his eyes with his hands. At 1:03 PM R3's eyes had a small amount of matter on the lower lids.R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment. R3's active diagnoses list includes ectropion of right and left lower eyelids (drooping of eyelids).R3's Progress Note, recorded by V12 Nurse Practitioner, dated 4/10/25 documents R3 continues to have ectropion and chronic blepharitis (inflammation) to bilateral eyelids, Systane Complete ophthalmic solution ordered, continue current management.R3's active Physician's Orders include an order dated 4/1/25 for Systane Complete Ophthalmic Solution apply one drop to each eye twice daily. There are no other orders for eye drops.On 7/24/25 at 11:08 AM V3 Licensed Practical Nurse stated staff apply a warm washcloth a couple times per day and R3 receives scheduled eye drops. V3 removed a box of Ketotifen Fumarate 0.035% eye drops labeled with R3's name. V3 stated R3 has a chronic problem with his eyes that cause pain and irritation, and R3 rubs his eyes a lot. At 12:32 PM V3 stated Ketotifen eye drops are used in place of the Systane, as they are the same. The medication cart was viewed with V3 who confirmed Ketotifen were the only eye drops for R3 in the medication cart, and there were no bottles of Systane eye drops labeled with R3's name. On 7/24/25 at 2:16 PM V7 Pharmacist stated Systane eye drops are for dry eyes, and Ketotifen eye drops are for allergies/allergic conjunctivitis, these are not the same. V7 stated if they were interchangeable there would be a physician's order and the pharmacy would have notified the facility. V7 stated V7 does not see Ketotifen on R3's order profile.On 7/24/25 at 2:38 PM V2 Director of Nursing stated nurses should follow physician's orders, and today V3 told V2 about R3's eye drops not matching the physician order. The Facility Physician/Practitioner Orders Policy Dated 2/10/2025 documents the Facility will verify that the order and original, valid prescription match. The facility will forward the original, valid prescription with the verification order to the pharmacy per protocol. The policy also documents if the orders (i.e. dose or frequency) do not match, or in the absence of an original, valid prescription, obtain an original, valid prescription and forward it along with the written order to the pharmacy per protocol. Page 1 of 2 145031 145031 07/29/2025 Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their pest control policy for four residents (R3, R5, R12, R13) reviewed for Pest Control in the sample list of 15 residents. On 7/24/25 at 12:38 PM V6 Housekeeper stated V6 has seen roaches in the hallways and resident rooms, which started around March or April, and is most prominent on the Downtown [NAME] hallway.On 7/24/25 at 1:18 PM V8 Certified Nursing Assistant stated over the past year V8 has noticed roaches on the walls in hallways and resident rooms, mostly on the downtown west hallway.On 7/24/25 at 1:08 PM R3 attempted to enter R3's room. V3 Licensed Practical Nurse redirected R3 away from his room and told him his room was just sprayed. R3's room and R5, R12, R13 had the doors closed with signs posted on the door indicating the room had been sprayed with pesticide treatment and required ventilation until 4:16 PM. At 1:11 PM R12 stated he has had a couple of roaches on the floor in his room. V3 stated V3 noticed bugs in the facility starting in October, and V3 has seen bugs in R12, R13, and R6's rooms. At 1:17 PM R13 called surveyor over to point out a roach like bug that was on the floor across the hallway from R13's room. V3 confirmed the bug and confirmed this was the type of bug V3 was referring to. At 1:39 PM R13 pointed out another roach like bug that was in the middle of the downtown west hallway near R13's room.On 7/24/25 at 2:30PM V16 Pest Control Technician stated he was called to the facility on 7/24/25 for bugs in resident's rooms.On 7/24/25 at 2:40PM V16 stated he received an email on 7/24/25 at 2:33AM as a work order for bugs in resident's rooms.The Facility pest control policy dated 1/2/23 documents the facility will maintain an effective pest control program that eradicates and contains common household pests and rodents. This document also states to ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures. The facility will utilize a variety of methods in controlling certain seasonal pests and will report system of issues that may arise in between scheduled visits. Residents Affected - Some 145031 Page 2 of 2