Inspection·November 1, 2024

F 0690 Level of Harm - Actual harm Residents Affected - Few c/o (complained of) pain and discomfort with catheter. (V24) assessed the area, no signs and or symptoms of infection or irritation. Area is free from malodourous scent and no redness or swelling present. (V24) flushed catheter and there was no resistance or blockage noted. (R5) has output, which is at 200 milliliters, urine does not have any blood clots, or any abnormality to color. Catheter bag was placed below waist height and secured. From 9/26/24 through 10/2/24 no evidence of further documentation regarding catheter monitoring was noted. R5's ED (Emergency Department) Note, dated 10/2/24 and signed by V14/emergency room Doctor, documents HPI (History of Present Illness): (R5) is an [AGE] year-old male comes in for further evaluation. (R5) was brought in by ambulance. (R5) was little obtunded is complaining of abdominal pain. (V22/R5's POA (Power of Attorney) saw (R5) yesterday at the (local nursing home) and felt (R5) was a little bit more out of it and a lot more lethargic. This same note documents, Abdomen: Abdomen is distended, tender in suprapubic region. Genitals: (R5) has an indwelling catheter that was noted to be twisted and when it was untwisted no drainage was coming from it. (R5) has significant erythema/yeast dermatitis in the groin and inguinal area. Once it was discovered the indwelling catheter was twisted, it was untwisted and nothing drained. Thick mucus/exudate was drained some, bladder scan showed greater than 1200 cc/cubic centimeters in bladder, a large CBI (Continuous Bladder Irrigation) catheter was placed and finally the bladder started to drain thick exudate. Concern for Sepsis: Yes, Source of infection: Sepsis Infection Source: Urinary, Sepsis/severe/septic shock. On 10/28/24 at 10:10 AM R5 was lying in his bed with his catheter drainage bag secured to the side of R5's trashcan. No kinks were noted in R5's catheter tubing. R5 was unable to recall going to the hospital. On 10/30/24 at 1:15 PM V12/LPN stated, I worked with (R5) four or five days prior to (R5) being sent to the hospital. (R5) was complaining of some discomfort with his catheter. When I went to observe (R5's) indwelling catheter, the catheter and the tubing was kinked. As soon as I untwisted the catheter, urine started flowing back into the drainage bag. V12/LPN stated she does not assess or monitor a resident's catheter when she works. V12 stated, I sign out the order for catheter care, but the CNAs (Certified Nursing Assistants) are supposed to perform catheter care, so I assume they are. I don't monitor catheters or chart on them unless an issue is reported to me. On 10/31/24 at 11:35 AM V6/LPN stated, We (the licensed nurses) do not do catheter care or monitor resident's catheter every shift. The CNAs are supposed to do that, and I assume they do. We do not chart on clarity or color or patency of the catheter as I do not check them unless an issue is reported to me by a CNA. V6 also stated that R5 had a physician order for catheter care every shift, but the nurses do not perform the catheter care, they just mark it off as complete assuming the CNAs are doing it. On 10/31/24 at 12:10 PM V21/CNA stated, I took care of (R5) on 10/1/24. (R5) wasn't acting right or himself so I went and told (V19/LPN) that (R5) wasn't acting right, was having diarrhea, and had the hiccups. I did not pay attention to (R5's) catheter whether it was twisted or not. On 10/31/24 at 12:15 PM V18/CNA stated, On 10/1/24 (V22/R5's Power of Attorney/POA) requested for us to clean (R5) up due to (R5) having diarrhea. (V22) stated (R5) was lying in diarrhea and was not acting himself. When I went and changed (R5) I noticed (R5) had some thick reddish drainage in (R5's) catheter bag. It was also not normal for (R5) to lay around like he was, (R5) is usually up moving around the building. I reported the thick reddish colored urine to (V19/LPN) and let her know (R5) was having diarrhea as well and not acting right. (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 11/01/2024 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)

F 0690 Level of Harm - Actual harm Residents Affected - Few On 10/31/24 at 11:40 AM V19/LPN stated, I worked with (R5) a few shifts prior to (R5) being sent to the Hospital. On 9/30/24 and 10/1/24 (R5) did not leave his room which is not normal for him. Staff reported to me that (R5) was barely eating or drinking anything and wasn't having a lot of output. (R5) did have some episodes of diarrhea and hiccups both days I worked so I just monitored him. I did not do an assessment on (R5) or observe (R5's) indwelling catheter. V19/LPN also stated, We (the nurses) never perform catheter care on any resident, and I do not monitor catheter tubing or catheters to see if it is free of kinks or draining appropriately. The only time I will look at anyone's catheter is if they have a complaint something hurts. I did not assess (R5's) catheter bag or drainage tubing when staff reported to me on 10/1/24 that (R5) was not acting right. (V12/LPN) had been reporting something was a little off with (R5) prior to 10/1/24 and (R5) had issues with his catheter being kinked, but the only thing I reported to (V26/R5's Primary Physician) on 10/1/24 was (R5) had been having diarrhea and hiccups for the past few days. On 10/31/24 at 8:13 AM V14/emergency room Doctor stated that when R5 arrived in the Emergency Room, R5 was lethargic and R5's abdomen was distended. Upon assessment of R5, R5's catheter tubing was severely twisted into a pretzel and dirty. R5's indwelling catheter was unable to be flushed. V14 stated, When I was finally able to remove (R5's) indwelling catheter, thick pus was coming out. (R5's) bladder scan showed more than 1200 cc/cubic centimeters of urine in (R5's) bladder. (R5's) bladder couldn't drain because of how much pus was in his abdomen which caused (R5's) kidneys to shut down and (R5) had to be admitted to Intensive Care Unit. The urine was thick and foul smelling after we did a bladder irrigation for (R5). On 10/31/24 at 9:40 AM V22/R5's POA (Power of Attorney) stated, The day before (R5) was sent to the emergency room (R5) was not acting right when I was visiting him. (R5) was laying in diarrhea when I arrived at the facility and (R5's) pants were pulled halfway down. (R5's) diarrhea was dried as if no one had even checked on him. (R5) was not acting right and was very out of it. I reported it to his nurse (not aware of her name) and told them my concerns. The nurse stated she would do an assessment and have the CNA clean him up. When a CNA finally came in to clean (R5) up and I ended up leaving for the day. I had not heard anything from the facility regarding (R5's) condition so I went in the next day to check on (R5). (R5) was lethargic, laying there motionless, and in the same position he was in from the day before. (R5) was very sick. (R5) has dementia and cannot take care of himself. The staff think (R5) can, but he can't. (R5) needs to be monitored and provided with assistance more frequently. On 10/31/24 at 10:55AM V2/Assistant Director of Nursing stated she is not aware of the nurses documenting on catheter color/clarity or the catheter tubing being patent each shift on (R5). V2 stated, I know some of the staff think that (R5) can empty his own urinary draining bag or take care of his own catheter, but (R5) cannot. (R5) has Dementia and his indwelling catheter should be monitored at least every shift to ensure no kinks are in (R5's) indwelling catheter and that its draining normal without signs of infection. There is a lot of training that needs to happen. On 10/31/24 at 11:03 AM V4/Interim Director of Nursing stated the nurses should be documenting on indwelling catheters at least daily. V4 stated, The nurses should be monitoring the resident's indwelling catheter tubing, documenting on color/clarity, and if any sediment is noted in an indwelling catheter draining bag or tubing. They should also be ensuring the catheter tubing is patent and draining urine freely. I know they are not doing that now. We (the facility) have a lot of new nurses and I believe it's caused by lack of training that we are working on now. On 10/31/24 at 6:36 PM V23/Agency LPN stated, When I arrived on my shift on 10/2/24, I received (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 11/01/2024 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)

F 0690 Level of Harm - Actual harm report that (R5) had been having diarrhea, hiccupping, and belching for at least the past two days and that (R5) was not acting like himself. When I assessed (R5) you could see (R5's) abdomen was clearly distended. I did not check (R5's) catheter tubing or urinary drainage during that time, I just sent him out to the Emergency Room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145431 If continuation sheet Page 4 of 4