Inspection·September 1, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a resident (R5) from physical abuse from another resident (R4). This failure affects two of three residents (R4 and R5) reviewed for abuse in the sample of six. Findings include: The facility's Abuse, Neglect, and Exploitation policy dated 12-5-22 documents, Policy: Each resident has to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies, family members, legal guardians, friends, or other individuals. Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 is cognitively intact. R5's MDS assessment dated [DATE] documents R5 is severely cognitively impaired. The facility's Final State Report dated 8-22-24 and signed by V6 (Administrator) documents, CNA/Certified Nursing Assistant (V10) notified abuse coordinator about (R4) hitting (R5). (V10) immediately removed (R5) from the area. (R5) has three small scratches on left side of face. Allegation of abuse substantiated. V3's (Local Police Officer's) Incident Report #24-EURK-03129 dated 8/21/2024 documents, I (V3) made contact with (the facility) Administrator (V6) in regard to (R4) that had struck another resident (R5) in the face approximately three times with her hand on 08/17/2024 at approximately 11:30 hours. V6 stated that another employee (V10/CNA/Certified Nursing Assistant) had checked on (R5) on said date and time because (R5's) door was shut. According to (V10's) statement (V10) checked on (R5) and asked him why his door was shut. (R5) informed (V10) that (R4), who lives across the hall, entered his (R5's) room, yelled at (R5). and smacked (R5) in the face approximately five times. (V10) also states that (R5's) face was red and he did have two fresh scratches on his face with blood. According to (V10), (R4) functions normal and is aware of the actions she takes. (V10) stated she reviewed the hallway video and observed (R4) walk into (R5's) room then walk back to (R4's) room approximately thirty seconds later, during the time of the incident. V10's statement dated 8-17-24 documents, I (V10) went to get (R5) up for lunch. When I got to (R5's) room, I noticed his door was shut. (R5) replied that the lady (R4) across from him came to (V5's) (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: 145431 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 09/01/2024 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)