Health inspection·July 2, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few effectiveness were monitored. V1 stated We just had a (Citation) for this, not three months ago. For these same two residents. V1 provided all related information. R2's Medical Record and psychiatric evaluations done after previous incident of R2 sexually abusing R1 on 4/1/24 document diagnosis of depression, posttraumatic stress disorder, and sexually inappropriate behavior. The Abatement plan dated 4/2/24 documented that R2 would be put on 1:1 supervision. The State Report dated 6/2/24 documents that at approximately 6:30 AM V3 (Certified Nurse Aide) witnessed R1's right hand up the shirt of another resident (R2). The written staff interviews from the date of the incident 6/2/24 document that V14 (Certified Nurse Aide) got R2 up and ready on 6/2/24 and left her in her room around 6:20 AM. The statements document that on 6/2/24 around 6:30 AM V3 (Certified Nurse Aide) and V14 (Certified Nurse Aide) both saw R2 wheel herself up to R1 in the lobby and put his hands on her breasts under her shirt. V14 (Certified Nurse Aide) noted that R2 stated I know I am not supposed to touch him, but it feels so good. R1's Minimum Data Set Assessment (dated 02/28/24) documents a Brief Interview of Mental Status score of 6, indicating severe cognitive impairment. R2's Care Plan last updated on 4/12/24 documents (R2) has a potential for behavior problem due to personal dynamics, false statements of staff, rejection of cares, crying, repetitive activities, attention seeking behaviors, non-compliance of cares, facility policy, manipulative behaviors towards staff, poor safety awareness, refusal to go to doctor's appointments or counselling, inappropriate behaviors, attempting to touch others. On 6/28/24 at 10:30 AM R2 was in bed, alert and oriented to time, place and situation. R2 was very upset about having a 1:1 care giver states I don't need a baby sitter. R2 confirmed that she put R1's hand on her breast. Stated It felt good, he and I are lovers and I don't care what you think. When asked if she thought R1 could consent to being touched or by being made to touch her, R2 stated I think he (R1) knows that he is a warm blooded man and he wants it. I do believe that. R2 confirmed that she understands that R1 cannot answer any simple yes or no questions for himself yet she stated she felt that he (R1) would love to feel my breast, I can tell when he (R1) wants to. On 6/29/24 at 9:00AM V2 (Director of Nursing) confirmed that she was aware of issues of R2 being found sexually abusive to R1 in the recent past (4/1/24.) V2 stated she came to work on 6/2/24, she got in verbal report that (R2) was in her room. V2 stated I then carried on about my day as normal until (V9/Certified Nurse Aide) brought R2 to me and explained that she had just witnessed R2 put R1's hands on her breasts. V2 stated When they (previous staff) said she (R2) was in her room, I assumed they meant in her bed, I didn't check, and she was actually up in her chair, and she can propel herself once up in the chair. V2 confirmed that R1 is in a reclining cushioned wheelchair that he is completely dependent on staff moving for him and that R2 can propel her wheelchair independently once she is up. V2 reported that as of 6/2/24 R2 had been changed to increase monitoring after her previous issues with R1. V2 stated that we had meetings and kind of went over her behaviors and stuff. I don't really remember when she came off of 1:1 and became increased monitoring. On 7/1/24 V1 (Administrator) stated that R2's 1:1 monitoring was discontinued as of 4/4/24 and she was on increased monitoring from 4/4/24 until the date of the second incident on 6/2/24. On 6/29/24 at 9:30 AM V1 (Administrator) stated that increased monitoring is kind of like a step down from being on 1:1, we want to always know where the resident is. For example, if a CNA took a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145431 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 145431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident that is on increase monitoring to an activity, she would stop and tell an activity member that she is leaving the resident there and for that person to keep an eye on her. V1 stated that there would be no documentation of such monitoring of an increase monitoring resident, and she also could not provide a written policy on increase monitoring. While the Immediacy was removed on 6/2/24, the facility remains out of compliance at a Severity Level II as additional time is needed to implement and evaluate effectiveness of their removal plan and quality improvement plan. 1. Immediate action(s) taken: On 6/2/2024, R2 was put on 1:1 supervision when out of bed and will continue on 1-1 supervision, that removed the immediacy. On 6/5/2024, Staff were in-serviced by LNHA(V1/Administrator) and IDT (Interdisciplinary Team) regarding facility abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident. Psychiatric services and psychotherapy will continue, and SSD notified Psych provider on 6/4/2024 of recent behaviors. IDT revised and reviewed care plans for R2 and R1 to identify patterns in residents' behaviors and implement interventions. Care plan revisions and interventions communicated to the nursing staff, activity staff and IDT that are caring for R1 and R2. On 6/7/2024, R1 was interviewed by LNHA for any signs or symptoms of psycho-social changes and no changes were noted. R2 will not be seated near male residents during dining, activities, etc. 2. Immediate action(s) taken to ensure all abuse issues are reported and assessed: On 6/5/2024, Staff were in-serviced by Administrator and IDT regarding facility abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident. 3. Immediate action(s) taken to ensure all abuse issues are reported and assessed: Administrator, SSD, and DON interviewed a sample of employees regarding any concerns, or reports, of resident abuse, with emphasis on inappropriate touching. On 6/5/2024 Administrator and DON educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. The outcomes of these evaluations will be used to determine next steps for care and treatment which could include continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. 4. Immediate action(s) taken to ensure the facility is continuing to monitor for and address any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145431 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 145431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530 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 0600 Level of Harm - Immediate jeopardy to resident health or safety concerns regarding abuse or neglect. Director of Operations with The [NAME] will meet with department managers to educate regarding their roles and responsibilities related to abuse/neglect prevention, reporting, investigation, and follow-up. All concerns related to abuse/neglect within the facility will be reviewed by the QA team in regularly scheduled meetings, next scheduled for July 25, 2024, as well as through the QAPI process. Residents Affected - Few SSD or Designee with interview 5 residents and 5 staff members, each week for 6 weeks, to ensure no complaints or concerns of abuse have been noted. Medical Director has been notified of IDPH concerns and will continue to participate in the QA process. On 7/2/24 the surveyor confirmed through observation, interview and record review the facility fully implemented all components of its abatement plan and immediacy was removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145431 If continuation sheet Page 4 of 4