Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to assess a resident after an unwitnessed fall and failed to
assist a resident off the floor following an unwitnessed fall for one (R3) of three residents reviewed for
Quality of Care and Dignity on a sample list of five residents. Based on interviews with the family, this
resident suffered psychosocial harm as a result of the resident being left on the floor.Findings includeR3's
Electronic Medical Record (EMR) documents that R3 had Alzheimer's Disease with early onset and Adult
Failure to Thrive.R3's Minimum Data Set (MDS) dated [DATE], documents R3 had cognitive impairment
with disorganized thinking, and inattention with altered levels of consciousness that fluctuated. This MDS
also documents that R3 was not capable of making her own decisions and that R3 was dependent on staff
to get from a sitting to standing position.R3's admission fall risk assessment dated [DATE] documents that
R3 was at risk for falls.R3's Care Plan dated 10/23/25, documents that R3 was at risk for falling related to
dementia, side effects of medication, and a terminal condition.R3's Care Plan dated 10/30/25, documents
that R3 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's
disease with interventions to supervise resident as needed.On 11/25/25 at 12:40 PM, V18 Certified Nurse
Assistant (CNA) stated V18 sat right outside of R3's room the night of R3's unwitnessed fall. V18 stated V18
went on her lunch break sometime during the middle of the night and when she returned V19 CNA told her
that R3 was found on the floor in R3's room. V18 CNA stated she reported this to V7 Registered Nurse
(RN) and V7 RN told V18 CNA that R3 likes to be on the floor and that the family said it's ok. V18 CNA
stated V7 RN never went to R3's room and assessed R3.On 11/25/25 at 1:11 PM, V19 CNA stated that she
found R3 on the floor and reported it to V7 RN and V7 RN told V19 CNA to leave R3 and the floor. V19 CNA
stated V7 RN did not go to R3's room to assess R3 after being found on the floor.On 11/25/25 at 2:51 PM,
V7 RN stated she was the nurse on duty at the time of R3's fall. On 11/20/25 V7 RN went on lunch break
around 12:50 AM and when V7 returned V19 CNA told her that R3 was found on the floor. V7 RN stated
that V8 Licensed Practical Nurse (LPN) told V7 RN in shift report that R3 would sometimes put herself on
the floor and that it would not be considered a fall. V7 RN stated V7 made a mistake in not documenting the
unwitnessed fall. V7 RN stated she did not assess the resident as V7 RN did not consider this a fall.On
11/25/25 at 10:23 AM, V22 Laundry Aide stated she found R3 on the floor around 6:15 AM on 11/20/25 and
that there was a pillow behind R3's back and R3's head was propped against the wall.On 11/25/25 at 11:03
AM, V23 Housekeeper stated she saw R3 lying on the floor with her head leaning against the wall and
dresser on the morning of 11/20/25. On 11/25/25 at 11:13 AM, V20 Activities Aide stated she recalls that on
the morning of 11/20/25 her coworkers told her to go find help because R3 was found on the floor. V20
Activities Aide stated she told a nurse and CNA (unsure of their names) and they did not do anything.On
11/25/25 at 11:20 AM, V21 Activity Director stated V23 Housekeeper came to V21 Activity Directors office
on the morning of 11/20/25 and stated R3 was lying
(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 4
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
12/01/2025
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)
F 0550
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
on the floor and needed help. V21 Activity Director stated she went to R3's room found her lying on the floor
partially on a fall mat, not covered up, with a pillow behind her back, and R3's head was leaning against the
wall.On 11/25/25 at 10:35 AM, V11 Licensed Practical Nurse (LPN) stated she was the nurse coming on
duty the morning R3 was found on the floor. V11 LPN stated V1 Administrator came to V11 LPN and asked
V11 LPN why R3 was on the floor. V11 LPN stated V7 RN did not tell V11 LPN that R3 was found on the
floor during the night. On 11/24/25 at 2:36 PM, V17 CNA stated she overheard V1 Administrator on the
morning of 11/20/25 loudly addressing staff after finding R3 lying on the floor saying, what if this was your
family member that was left lying on the cold floor?On 11/25/25 at 9:49 AM, V1 Administrator stated she
found R3 floor in R3's room around 6:55 AM. V1 Administrator stated R3 was partially lying on a fall mat,
not covered, and was not arousable. V1 stated this was unacceptable that the nurse should have assessed
R3 immediately when the unwitnessed fall was reported and gotten R3 up off the floor and into her bed. On
11/25/25 at 2:43 PM, V24 (R3's) Husband tearfully stated if R3 had the ability to communicate on 11/20/25
when R3 was found on the floor, R3 would have been anxious, pissed off and questioning how she got on
the floor and why she was left there. The facility's Resident Right's Policy dated 2/12/25 documents that the
resident has the right to a dignified existence, self-determination, and communication with and access to
persons and services inside and outside the facility. This policy documents the following:2. Exercise of
rights. The resident representative has the right to exercise the resident's rights to the extent those rights
are delegated to the resident representative. 5. Respect and dignity. The resident has a right to be treated
with respect and dignity, including: the right to reside and receive services in the facility with reasonable
accommodation of resident needs and preferences, except when to do so would endanger the health or
safety of the resident or other residents.9. Safe environment. The resident has a right to a safe, clean,
comfortable and homelike environment, including but not limited to receiving treatment and supports for
daily living safely.
Event ID:
Facility ID:
145031
If continuation sheet
Page 2 of 4
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
12/01/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure a resident was properly supervised to prevent a fall
for one (R3) of three residents reviewed for accidents on a sample list of five. Findings include:R3's
Minimum Data Set (MDS) dated [DATE] documents that R3 was not able to complete the Brief Interview for
Mental Status (BIMS) due to cognitive impairment.R3's admission fall risk assessment dated [DATE]
documents R3 is at risk for falls.R3's Care Plan dated 10/23/25, documents that R3 is at risk for falls related
to dementia, side effects of medication and a terminal condition.R3's Care Plan dated 10/30/25, documents
that R3 is an elopement risk/wanderer related to R3 is disoriented to place and has impaired safety
awareness.R3's progress notes document that on 11/20/25 at approximately 6:00 AM R3 was observed on
the floor in R3's room.On 11/25/25 at 12:40 PM, V18 Certified Nurse Assistant (CNA) stated V18 sat right
outside of R3's room the night of her unwitnessed fall. V18 stated V18 went on her lunch break sometime
during the middle of the night and when she returned V19 CNA told her that R3 was found on the floor in
R3's room. V18 CNA stated that she got R3 off the floor around 4:30 AM to toilet R3 and then left R3 sitting
on the edge of R3's bed. V18 CNA stated that around 6:00 AM while doing change of shift rounds R3 was
found lying on the floor again next to R3's bed.On 11/25/25 1:11 PM, V19 CNA stated that she found R3 on
the floor and reported it to V7 RN and V7 told V19 CNA to leave R3 and the floor. V19 CNA stated V7 RN
did not go to R3's room to assess R3 after being found on the floor.On 11/25/25 at 2:51 PM, V7 Registered
Nurse (RN) stated she was the nurse on duty at the time of R3's fall on 11/20/25 and that V7 RN went on
lunch break around 12:50 AM and when she returned V19 CNA told V7 that R3 was found on the floor. V7
RN stated that V8 Licensed Practical Nurse (LPN) told V7 RN in shift report that R3 would sometimes put
herself on the floor and that it would not be considered a fall. V7 RN stated V7 RN made a mistake in not
documenting the unwitnessed fall. On 11/25/25 at 9:49 AM, V1 Administrator stated that V1's expectation of
the staff was that they should have partnered with their coworkers to keep a close eye on R3 to prevent falls
and keep R3 safe and comfortable. The facility's fall policy dated 2/12/25 documents that each resident will
be assessed for fall risk and will receive care and services in accordance with their individualized level of
risk to minimize the likelihood of falls. Definitions: a fall is an event in which an individual unintentionally
comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The
event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can
occur anywhere. The nurse will indicate on the Fall Risk Assessment/Morse Fall Assessment the resident's
fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level
of risk. This policy documents that the facility will provide interventions that address unique risk factors
measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in
functional status and provide additional interventions as directed by the resident's assessment, including
but not limited to: assistive devices, increased frequency of rounds, sitter, if indicated, medication regimen
review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver
or resident education and therapy services referral.
Event ID:
Facility ID:
145031
If continuation sheet
Page 3 of 4
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
12/01/2025
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to ensure a resident was kept free from a significant
medication error for one (R3) of three residents reviewed for medication management on a sample list of
five residents. Findings include:R3's Electronic Medical Record (EMR) contained a physician's order dated
10/22/25 documenting that R3 was to receive Haloperidol (HALDOL) two milligrams (mg)/ milliliter (ml)
concentrate, take one ml by mouth every eight hours for agitated movements accompanied by emotional
distress. R3's physician orders in R3's EMR dated 10/22/25 document an order for Haloperidol Lactate Oral
Concentrate two mg/ml, give two ml by mouth every eight hours for agitation/restlessness.R3's October and
November 2025 Medication Administration Record (MAR) documents that R3 received seventy-three
incorrect doses of Haloperidol. R3's EMR contains a letter dated 11/20/25 documenting that V2 Assistant
Director of Nursing (ADON) reported R3's Haloperidol medication error to Physicians Group. This letter
documents that R3 was lethargic that day. On 11/25/25 at 12:02 PM, V2 Assistant Director of Nursing
(ADON) stated V3 [NAME] President of Clinical Services did a medication audit after R3's unwitnessed fall
and found that R3's physician order for Haloperidol two mg/ml, give one ml every eight hours was
transcribed incorrectly as Haloperidol two mg/ml, give two ml every eight hours. V2 ADON stated validation
by a second nurse is not facility policy but V2 ADON thinks it should be. On 12/01/25 at 10:00 AM, V3
[NAME] President of Clinical Services stated the nurse that incorrectly transcribed R3's physician's order
for Haloperidol has been terminated and that an unwritten policy of the facility is that a second nurse should
validate the physician's order that were entered into a resident's chart. V3 stated validation by a second
nurse should have been done. The facility's Physician/Practitioner Orders Policy dated 2/10/25 documents
that the attending physician shall authenticate orders for the care and treatment of assigned residents. This
policy documents the following explanation and compliance guidelines: 2. for physician/practitioner orders
received in writing or via fax, the nurse in a timely manner will: a. if not the attending, call the attending
physician to verify the order and b. follow facility procedures for verbal or telephone orders including noting
the order, submitting to pharmacy, and transcribing to medication or treatment administration record.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145031
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the December 1, 2025 survey of LOFT REHAB & NURSING OF NORMAL?
This was a inspection survey of LOFT REHAB & NURSING OF NORMAL on December 1, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LOFT REHAB & NURSING OF NORMAL on December 1, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.