Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to provide a completed transfer document for one resident
(R68) of 2 residents reviewed for discharge in a total sample of forty.
Findings Include:
The Facility's Transfer and Discharge policy dated 1/30/24 documents Orientation for transfer or discharge
must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a
form and manner that the resident can understand. Depending on the circumstances, this orientation may
be provided by various members of the interdisciplinary team.
The Facility's Transfer and Discharge policy dated 1/30/24 documents for Emergency Transfers/Discharges
that the nurse will Complete and send with the resident (or provide as soon as practicable) a Transfer Form
which documents: Resident status, including baseline and current mental, behavioral and functional status
and recent vital signs; Current diagnosis, allergies and reason for transfer/discharge; Contact information of
the practitioner responsible for the care of the resident; Resident representative information including
contact information; Current medications (including when last received), treatments, most recent relevant
lab and. or radiological findings and recent immunizations; Special instructions or precautions for ongoing
care to include precautions such as isolation or contact; special risks such as risk for falls, elopement,
bleeding or pressure injury and/or aspiration precautions, comprehensive care plan goals, and any other
documentation, as applicable, to ensure a safe and effective transition of care.
R68's Electronic Medical Record documents that R68 was admitted on [DATE] after a Cerebral Vascular
Accident for therapy with an anticipated return to home after therapy was completed.
R68's Physician Order Sheet for May 2024 documents that R68 was receiving Skilled Therapy during his
stay,
R68's Physician Order Sheet for May 2024 document that R68 was receiving Apibaxin 5 mg (milligrams)
(anti-coagulant medicine) daily.
R68's Nurse's Notes dated 5/24/24 at 9:24 AM document that R68 left the physical therapy department
independently in his wheelchair and staff attempted to redirect him to finish his therapy due to his repeated
refusals to complete the whole sessions. The Nurse's Note documents Resident sitting in middle of hallway,
resident is having behaviors. Resident purposefully sliding out of his wheelchair as he did not want to wheel
himself back to his room. Resident asking female staff for their
(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 14
Event ID:
145600
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
personal phone number. Resident assisted back up in his chair using gait belt and several staff members.
Resident taken to his room and started demanding we send him out to hospital because he wants to leave.
Several minutes later he reported to staff he had facial numbness (of) bilateral arms (and) legs numbness.
(Doctor) was notified and he gave an order to send resident to (Local Emergency Room) for evaluation.
R68's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 5/24/24 has area
for Reason for transfer that was blank, area Primary Care Clinician in SNF/NF was blank, Risk Alerts area
was blank, Immunizations area was blank, Behavioral Issues and Interventions area was blank,
Rehabilitation Therapy: Is the Resident/Patient currently receiving Rehabilitation Therapy? was not
answered.
On 8/21/24 at 10:30 AM V2 (Director of Nursing) stated she didn't know why the areas were blank because
she was not the one who filled out the form. V2 provided R68's eInteract Transfer Form dated 5/24/24 and
stated that the form could be considered R68's transfer form/discharge summary.
R68's eInteract Transfer Form dated 5/24/24 has area Primary Diagnosis for admission to your Facility that
was blank, Transfer/Discharge Details area was blank, Risk Alerts: Precautions: currently on isolation
precautions? was not answered, Risk Alert: Other Risks area was blank, Behavior area was blank,
Immunizations area was blank, Rehabilitation Therapy Is the resident/patient currently receiving
Rehabilitation Therapy? was not answered, Primary Care Clinician in SNF/NF area was blank.
R68's Acute Care Transfer Document Checklist documents Documents Recommended to Accompany
Resident/Patient: Resident/Patient Transfer Form, Personal Belongings identified on Resident/Patient
Transfer Form are enclosed, Face Sheet, Current Medication List or Current MAR (Medication
Administration Record), SBAR (Situation, Background, Assessment and Recommendation) and/or other
Change in Condition Progress Note (if completed), Advance Directives (Durable Power of Attorney for
Health Care Living Will), Advance Care Orders. None of the listed documents are marked as sent with R68
to the Emergency Room.
On 8/22/24 at 9:15 AM V2 stated she did not know why the forms were not completed because she was not
the person who transferred R68 to the hospital.
On 8/22/24 at 9:20 AM V1 (Administrator) confirmed that the forms should have been filled out in their
entirety and V1 confirmed that R68 had documented behaviors that should have been noted, and that R68
was on an anticoagulant and that should have been noted in the other risk areas where available on the
forms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 2 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to perform personal care for one
resident (R20) of twenty residents reviewed for clean and well kempt appearance in a total sample of forty.
Residents Affected - Few
Findings Include:
The Facility's Activities of Daily Living Policy dated 12/5/23 documents Care and services will be provided
for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. The policy also
documents A resident who is unable to carry out activities of daily living will receive the necessary services
to maintain good nutrition, grooming, and personal hygiene and oral hygiene.
R20's Electronic Medical Record documents that R20 was admitted for Hospice Care due to adult failure to
thrive and muscle wasting.
R20's Point of Care Response History documents that on 8/17/24 R20 was totally dependent for bathing
and grooming.
On 8/20/24 at 9:00 AM R20 was lying in bed in a hospital gown with full beard stubble with a longer
mustache that covered his entire lips. R20's fingernails were also long. R20 stated I've been asking (staff) to
shave me, I want the mustache trimmed and I don't want all of this (motioned to full beard stubble on
cheeks and neck). I need my damn nails cut too, I told the girl last night she said she would come back later
and do it but never did. I could cut paper with my nails.
On 8/22/24 at 10:00AM V8 (R20's family) stated (R20) needs shaved badly and he has told me a couple of
times about his nails, I keep trying to remember some clippers so I could do it for him. I don't know why they
(staff) haven't done it.
R20's Point of Care Response History documents that R20 received a shower on 8/20/24 by V6 (Certified
Nurse Aid).
On 8/22/24 at 10:05 AM R20 stated I told her (V6/Certified Nurse Aid) that I wanted shaved, and my nails
cut, and she said she would come back and do it and she never did.
On 8/22/24 at 11:00 AM V1 (Administrator) confirmed that it would be her expectation that unless there was
documentation of a resident refusing that all residents receive personal grooming to include being shaved
and nails clipped during a shower. V1 confirmed that R20's shower was marked as given and that there was
no documentation of R20 refusing personal grooming.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 3 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to complete diabetic monitoring and care for one of two
residents (R41) reviewed for quality of care in a sample of 40 residents.
Residents Affected - Few
Findings include:
R41's Minimum Data Set (MDS) documents R41 was admitted on [DATE] with Type 2 Diabetes Mellitus
with Insulin Dependence.
R41's Physician's Standing Orders, undated, documents Diabetes: Unless otherwise indicated: blood
glucose monitoring before meals and at bedtime. If no sliding scale ordered, may use the following scale .
R41's Hospitalization Discharge summary, dated [DATE], documents Insulin to be administered per sliding
scale every four hours.
R41's Progress Note document R41 returned to the facility post hospitalization on 8/16/24 at 3:45 PM.
R41's Blood Glucose Monitoring log documents a blood glucose level was conducted on the facility's
admission assessment on 8/16/24 at 5:30 PM and not again until 8/19/24 at 11:06 AM.
R41's Progress Note dated 8/19/24 at 10:09 AM documents Resident had been yelling out in the morning,
currently lethargic and slightly diaphoretic (sweating). Blood glucose levels checked, and resident is
currently at 471 (per sliding scale 60-150 blood sugar levels require no treatment). Twelve units of insulin
Lispro administered in reference to sliding scale standing order. Discharge orders (Hospital's Discharge
Orders) checked prior to administration, order for insulin Lispro on sliding scale noted in discharge orders
(Hospital's Discharge Orders). Doctor notified of elevated blood glucose levels.
R41's Progress Note dated 8/19/24 at 11:06 AM documents 1 (one) hour recheck blood glucose at 413, 15
units (Insulin) administered.
On 8/19/24 at 12:00 PM, a Physician's Order for Insulin administration per sliding scale was obtained.
R41's Progress Note dated 8/19/24 at 12:08 PM documents Second blood glucose level at one hour after
insulin administration, 413. Second dose of insulin administered via sliding scale guidelines. One hour post
second dose administration blood glucose level 311.
On 8/22/24 at 12:45 PM, V14 (Registered Nurse) confirmed R41's blood glucose levels were not monitored
per standing order nor where insulin orders obtained upon return to the facility post hospitalization on
8/16/24 until 8/19/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 4 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure catheter care was conducted for one of nine
residents (R41) with indwelling catheters in a sample of forty residents.
Findings include:
R41's Care plan, dated 7/29/24, documents Indwelling Catheter for wound healing. Monitor/record/report to
Medical Doctor for signs and symptoms Urinary Tract Infection: pain, burning, blood-tinged urine,
cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul
smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
R41's Progress Notes, dated 8/3/24 at 9:49 PM, documents Husband concerned that R41 may be getting a
Urinary [NAME] Infection. New Catheter bag in place for clean catch (urine sample). Will pass on to next
nurse to collect urine if signs and symptoms for urinalysis to be collected.
R41's Progress Notes, Physician Orders and Laboratory Results lacks documentation a urinalysis was
obtained.
R41's Progress Notes, dated 8/6/24 at 9:48 AM, documents R41 was sent to the hospital for evaluation for
a change in condition.
R41's Hospitalization Discharge summary, dated [DATE], documents During R41's admission [DATE]
through 8/16/24), R41 was treated with Intravenous antibiotics for pneumonia and a urinary tract infection.
R41's urine culture did have Pseudomonas Aeruginosa, Enterococcal Faecalis and Coag-negative
Staphylococcus.
On 8/16/24, the Progress Notes documents R41 returned to the facility with an indwelling urinary catheter.
R41's Treatment Administration Record (TAR) documents a Physician's Order for Catheter Care every shift
was obtained to start on 8/20/24 at 10:00 PM. The TAR documents catheter care was not conducted until
night shift on 8/20/24, 4 days after return to the facility post hospitalization.
On 8/22/24 at 12:45 PM, V14 (Registered Nurse) stated R41's (spouse) told me R41 said R41 felt like R41
had a kidney infection. R41 can be very cognizant at times. At home, R41 always told R41's (spouse) when
R41 felt the symptoms of an UTI (Urinary Tract Infection) and the spouse would call R41's doctor, get a
urinalysis and start antibiotics. R41's spouse said R41 always knew (when UTI was starting). So, when
R41's spouse told me that (R41 reported signs and symptoms of kidney infection) I changed the catheter
bag so we could get a clean catch specimen (urine). I don't know why it (urine sample) was never gotten. I
think R41's urine looked ok until the day R41 went to the hospital. It doesn't look like physician orders were
addressed until Monday, the 19th (8/19/24). Probably because it was a weekend.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 5 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to identify specific triggers of re-traumatization for
two residents (R1, R6) reviewed for PTSD (Post Traumatic Stress Disorder) of three residents reviewed for
Trauma Informed Care in the sample of 40.
Residents Affected - Few
Findings include:
Facility Policy/Trauma Informed Care dated 1/30/24 documents:
A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms
of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and
practices to avoid re-traumatization.
The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific
interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the
resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be
added to the resident's care plan. While most triggers are highly individualized, some triggers may include,
but not limited to:
Experiencing a lack of privacy or confinement in a crowded or small space.
Exposure to loud noises, or bright/flashing lights.
Certain sights, such as objects that are associated with their abuser.
Sounds, smells, and physical touch.
Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of
trauma such as substance-abuse, eating disorders, depression, and anxiety.
In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify
triggers which may re-traumatize the resident and develop care plan interventions which minimize or
eliminate the effect of the trigger on the resident.
Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE].
Trauma Informed Care assessment dated [DATE] indicates R1 had no history of trauma.
Trauma Informed Care Assessments dated 5/4/23 and 1/4/24 indicate R1 did have a history of trauma
described as child, sexual abuse/assault (including rape) - non-consensual sexual contact which caused
emotional harm. Assessments indicate symptoms exhibited are anger and tearfulness.
R1's current Care Plan indicates R1 has a history of trauma (child abuse/sexual abuse).
Care Plan interventions (dated 10/20/23) indicate (R1) will come and talk to Social Services or Nursing if
she is having triggers due to her history of sexual abuse until she restarts therapy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 6 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0699
Care Plan does not identify triggers for potential re-traumatization.
Level of Harm - Minimal harm
or potential for actual harm
On 8/22/24 at 12:20pm V15, Social Services/Care Plan Coordinator stated triggers should have been
identified and documented in R1's care plan.
Residents Affected - Few
2) Current Physician Order Summary Report indicates R6 was admitted to the facility on [DATE].
Trauma Informed Care Assessments dated 8/17/23 and 2/16/24 indicate R6 has a history of trauma
identified as sexual abuse/assault (including rape). Assessment indicates no symptoms or triggers per
resident.
R6's current Care Plan does not include PTSD or Trauma Informed Care including triggers/interventions.
On 8/22/24 at 12:25pm V15, Social Services/Care Plan Coordinator stated R6's care plan should have
included her diagnosis of PTSD and thinks it got overlooked.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 7 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Current
Physician Order Summary Report indicates R32 is [AGE] years old and was admitted to the facility on
[DATE].
Physician Order Summary Report dated 4/1/24 to 4/30/24 indicates Quetiapine 25 mg (milligrams) twice
daily was initially ordered on admit 4/2/24, for Unspecified Mood Disorder.
Current Order Report indicates R32 currently has orders for Quetiapine (antipsychotic) 50 mg (milligrams)
twice daily for Unspecified Mood Disorder was increased/ordered on 6/20/24.
Progress Note dated 6/7/24 indicates R32's family Would like the physician to do a face to face with (R32)
so she can determine whether (R32) is competent or not since she talks to family members about relatives
that are no longer alive.
Progress Note dated 6/11/24 at 6:42 PM indicates (R32's) family keeps calling staff demanding that he
wants (R32) to be deemed incompetent.
Progress Note dated 6/19/24 at 8 PM indicates R32 was showing signs of increased anxiety and increased
sadness. Note indicates R32's family called facility with same concerns and requested medication change.
Progress Note dated 6/20/24 at 1:24 PM indicates R32's family was wanting R32's medications adjusted
however, R32's antidepressant was just increased. Note indicates R32 Recently had a flare up of CHF
(Congestive Heart Failure) so she's been increase (ingly) complaining about everything and more whining
(more) than usual, (which) would be expected.
Progress Note dated 6/20/24 at 2:24pn indicates R32's PCP (Primary Care Physician) ordered (increased)
R32's Quetiapine to 50 mg twice daily.
Progress Note dated 8/4/24 at 11:58 AM indicates R32 was verbally aggressive, yelling and demanding to
go home.
Progress Note dated 8/7/24 3:29 PM indicates R32 very upset, yelling out that she wanted to go home
while receiving care from staff.
Consent for Psychotropic Medications dated 4/3/24 and 6/20/24 indicates Quetiapine was ordered for
Bipolar.
Review of R32's current diagnosis list and psychiatry notes found no diagnosis of Bipolar Disorder.
Most recent psychiatry note dated 8/1/24 indicates R32 has no audio/visual hallucinations or delusions.
Current Care Plan indicates R32 uses antipsychotic medication related to diagnosis of Mood disorder and
Depression. Care Plan indicates R32 is upset with placement and wants to go home. Care Plan
interventions indicate to monitor occurrence of target behavior symptoms - withdrawn, tearful, refusal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 8 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0758
of cares, agitation.
Level of Harm - Minimal harm
or potential for actual harm
Pharmacy Recommendations dated 6/12/24 indicates a Gradual Dose Reduction was recommended by
pharmacy for R32's Quetiapine. Physican response to recommendations indicated Condition is not well
controlled/stable and a reduction is likely to impair the resident's function and/or cause psychiatric
instability.
Residents Affected - Few
On all dates of the onsite survey 8/20/24, 8/21/24, 8/22/24 - R32 was seen self-propelling her wheelchair
through the facility and easily engaging with staff. On 8/20/24 R32 did have a concern regarding her family
taking over her finances, then later stated she spoke with staff and it was no longer a concern. R32 did not
exhibit any distress related to her concerns.
On 8/22/24 at 12:30 PM V15, Social Services/Care Plan Coordinator acknowledged R32's behaviors are
only being occasionally verbally aggressive and resistive to cares at times. V15 stated R32 has never been
physically aggressive.
On 8/22/24 at 12:40 PM V3, ADON/Psychotropic Nurse (Assistant Director of Nursing) stated R32's
behaviors are outbursts, yelling at staff and resistive to cares. V3 acknowledged she was not in agreement
with increasing R32's Quetiapine acknowledged R32's behaviors did not meet requirements for an
antipsychotic. V3 also acknowledged Bipolar was not the correct diagnosis documented on R32's
psychotropic consents.
3) Current Physician Order Summary Report indicates R39 is [AGE] years old and was admitted to the
facility on [DATE].
Current Order Report indicates R39 has orders for Quetiapine (antipsychotic) 25 mg (milligrams) in the
afternoon for verbal aggression, crying uncontrollably related to Vascular Dementia with Agitation (order
date 8/14/24).
Progress Note dated 8/7/24 at 2:40 PM indicates R39 was outside of the nursing office yelling and crying
out. Note indicates staff attempted to give R39 pain medication which R39 refused at that time.
Progress Note dated 8/7/24 at 3 PM indicates R39 Up at the nurses's desk upset and yelling out and
crying. Note indicates multiple staff unable to determine reason R39 was upset due to R39's word salad.
Note further indicates when R39 was able to calm down, staff able to determine that R39 was constipated
and wanted something to help.
Progress Note dated 8/11/24 9:10 AM indicates R39 had an unwitnessed non-injury fall in her room.
Progress Note dated 8/11/24 at 10:38 AM indicates R39's hearing aide was broken.
Progress Note dated 8/11/24 at 11:58 AM indicates a new order was received from psychiatry services to
start Quetiapine (antipsychotic) 25 mg daily.
Progress Note dated 8/12/24 at 11:28 AM indicates R39 had an unwitnessed non-injury fall in her room.
Progress Note dated 8/19/24 at 4:28 AM indicates R39 came out of her room and was crying and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 9 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0758
stating I can't stand this pain! and requesting nurse call the physician.
Level of Harm - Minimal harm
or potential for actual harm
R39's current Care Plan reviewed and found no care plan area to address Quetiapine/antipsychotic use or
identified target behaviors.
Residents Affected - Few
On all dates of the onsite survey 8/20/24, 8/21/24, 8/22/24 - R39 was seen sleeping or in her room in her
recliner chair. R39 did not exhibit any inappropriate behaviors.
On 8/22/24 at 12:40 PM V3, ADON stated Hospice ordered the Quetiapine for R39 and stated she advised
Hospice the current diagnosis was not appropriate for its use.
V3 stated R39 gets frustrated and mad due to not being able to express herself and not being understood
by staff. V3 stated that a lot of R39's behaviors are due to R39's pain and medication seeking. V3 stated
there has been a disconnect between nursing and care planning and R39's Quetiapine should have been
care planned along with target behaviors. V3 stated R39's behaviors are not constant or dangerous to
herself or others.
Based on observation, interview and record review, the facility failed to identify an appropriate indication for
use and identify target behaviors for the use of an antipsychotic medications for three of five residents
(R28, R32, R39) reviewed for unnecessary medications in a sample of forty residents.
Findings include:
Facility Policy/Use of Psychotropic Medication dated 9/27/23 documents Residents are not given
psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and
documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by
monitoring and documentation of the resident's response to the medication. Enduring Conditions (i.e.,
non-acute, chronic, or prolonged):The resident's symptoms and therapeutic goals shall be clearly and
specifically identified and documented. An evaluation shall be documented to determine that the resident's
expressions or indications of distress are:Not due to a medical condition or problems that can be expected
to improve or resolve as the underlying condition is treated or the offending medications(s) are
discontinued;Not due to environmental stressors alone, that can be addressed to improve the symptoms or
maintain safety;Not due to psychological stressors, anxiety, or fear stemming from misunderstanding
related to his or her cognitive impairment that can expected to improve or resolve as the situation is
addressed; and
Persistent, negatively affect his or her life.
1. The Medication Administration Record (MAR), dated 8/1/24 - 8/31/24, documents R28's has the following
diagnoses: Unspecified Mood Disorder and Unspecified Dementia, Unspecified Severity, without Behavioral
Disturbances, Psychotic Disturbances, Mood Disturbances and Anxiety. The MAR's Physician's order,
dated 6/11/24, documents Olanzapine (Antipsychotic medication) oral tablet 5 mg (milligram) at bedtime
related to unspecified mood disorder is administered daily.
R28's Careplan, dated 7/23/24, documents R28 uses Antipsychotic medication related to diagnosis of
Mood disorder and Dementia.
The Psychiatric Evaluation, dated 5/29/24, 6/7/24, 7/5/24 and 8/1/24, documents Psychiatric
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 10 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
History: No history of inpatient or out patient psychiatric care. No history of Suicidal Ideation. No history of
TMS (Transcranial magnetic stimulation), ETC (Electroconvulsive therapy) or any known psychotropic trials.
Staff report no acute concerns or agitation. Staff deny any new or worsening non redirectable dementia
related to behaviors. Staff deny noting any signs or symptoms of anxiety, depression, suicidal or homicidal
ideation. No indication of delusions, visual hallucinations, auditory hallucinations, mania or paranoia. Patient
remains at baseline mood without fluctuations. There are no indications of psychotic or manic features.
On 8/20/24, 8/21/24 and 8/22/24, R28 was observed and did not display any inappropriate behaviors or
signs/symptoms of psychosis.
On 6/10/24, the Progress Note documents (Primary Care physician) was notified R28 is on a antipsychotic
for Dementia related behaviors. However, R28 is not having any current behaviors per staff and per chart
review. R28 has also been noted to be very drowsy in the morning during our visits. If R28 is having
behaviors that i am unaware of please let me know. No Behaviors noted since being with us per nursing.
On 8/22/24 at 12:45 PM, V3 (Assisting Director of Nursing) stated V28 has not exhibited any behaviors
since admission and confirmed R28 did not have a psychiatric diagnosis. V3 stated R28 was admitted on
Olanzapine and it has not been changed. V3 stated I will ask for them to discontinue it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 11 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and record review, the facility failed to ensure food is prepared under sanitary
conditions by not using Personal Protective Equipment (PPE) properly to prevent hair from contacting food.
This failure has the potential to affect all residents with a current census of 65 residents.
Findings include:
The Hair Restraint; Jewelry; Nail Polish; False Eyelashes policy, dated 11/10/21, documents Food and
nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times
in the kitchen. [NAME] guards or masks will be worn as indicated. Dietary staff must wear hair restraints to
prevent their hair from contacting exposed food. If a hat is worn, a hairnet must be worn under the hat if any
hair is exposed from under the hat.
On 8/21/24 at 11:15 AM, two maintenance men (vendor) were observed to be in the kitchen working on an
ice machine without hair or beard restraints donned.
On 8/21/24 at 11:20 AM, V13 (Cook) was observed to have multiple pieces of hair exposed from under the
hair restraint while preparing lunch trays.
On 8/21/24 at 11:22 AM, V11 (Dietary Manager) stated the maintenance men should have donned hair
restraints and beard guards prior to entering the kitchen and the cook should've had all hair covered by the
hair restraint.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 12 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation
has 2 deficient practice statements.
Residents Affected - Some
A. Based on record review, observation and interview, the facility failed to wear Personal Protective
Equipment (PPE) appropriately, failed to disinfect patient use items and failed to conduct hand hygiene per
policy for one of three residents (R41) reviewed for infection control practices in a sample of forty residents.
B. Based on observation, interview and record review the facility failed to pass medications in a manner to
prevent contamination. This failure has the potential to affect the 19 residents who reside on the 400 hall
(R1,R5,R6,R12,R16,R19,R23,R26,R27,R31,R32,R36,R29,R46,R50,R54,R56,R60 and R61) in a total
sample of forty.
Findings include:
A. The Enhanced Barrier Precautions policy, dated 1/1/24, documents Enhanced Barrier Precautions (EBP)
refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that
employ targeted gown and gloves use during high contact resident care activities. b. An order for enhanced
barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling
medical devices even if the resident is not known to be infected or colonized with a MDRO (Methicillin-drug
Resistant Organism).
The Morbidity and Mortality Weekly Report Vol. 51 / No. RR-16 Guideline for Hand Hygiene in Health-Care
Settings, Recommendations of the Healthcare Infection Control Practices, Advisory Committee and the
HICPAC/[NAME]/APIC/IDSA, Hand Hygiene Task Force, 10/25/22, documents G. Decontaminate hands
after contact with body fluids or excretions, mucous membranes, nonintact skin and wound dressings if
hands are not visibly soiled J. Decontaminate hands after removing gloves.
R41 was admitted on [DATE] with sacral and ankle wounds, a gastrostomy tube, indwelling urinary catheter
and a history of urinary tract infections.
08/20/24 12:10 PM and 8/21/24 at 9:08 AM, an Enhanced Barrier Precaution sign was posted outside of
R41's room door.
On 8/21/24, V12 (Registered Nurse) and V10 (Certified Nurse Aide) were observed to provide wound care
without donning a gown. V12 was observed to clean stool from R41's buttocks and removed the dressing,
which was soiled with stool, removed gloves and donned new gloves without conducting hand hygiene.
After the dressing change, V12 removed gloves and proceeded to pick up the tube of ointment used during
treatment, applied the lid to the tube of ointment and put the ointment back into the ointment box without
conducting hand hygiene or wearing gloves.
On 8/22/24 at 10:00 AM V2 (Director of Nursing) stated PPE gowns should be secured with both ties, hand
hygiene should have been conducted before and after glove application and removal. V2 stated the tube of
ointment should have been considered dirty and should have been disinfected prior to replacing the
ointment back into the ointment box with clean gloves donned.B. The Facility's Medication Administration
policy dated 01/04/24 documents Medications are administered by licensed nurses, or other staff who are
legally authorized to do so in this state, as ordered by the physician and in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 13 of 14
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
145600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehab & Nursing of Canton
2081 North Main Street
Canton, IL 61520
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 0880
accordance with professional standards of practice, in a manner to prevent contamination or infection.
Level of Harm - Minimal harm
or potential for actual harm
On 8/21/24 at 8:05 AM V2 (Director of Nursing) prepared R5's scheduled morning medications in a
medicine cup. V2 knocked the medicine cup over on top of the medication cart and used her gloved hand to
scoop up the pills that came out onto to cart and put them back in the cup and then administered the
medications to R5.
Residents Affected - Some
On 8/22/24 at 10:00 AM V2 (Director of Nursing) stated I don't remember doing that, yesterday was crazy, if
I did, I shouldn't have. V2 confirmed that the top of the medication cart would not be considered a clean
surface and that all medications that came out of a medicine cup during medication preparation should be
discarded. V2 confirmed that the medication cart she had been working out of on 8/21/24 contained all the
medications for the 400 hall.
The Facility's Room Roster dated 8/20/24 documents that the following residents reside on the 400 hall:
R1,R5,R6,R12,R16,R19,R23,R26,R27,R31,R32,R36,R39,R46,R50,R54,R56,R60 and R61.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145600
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
11 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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the August 22, 2024 survey of LOFT REHAB & NURSING OF CANTON?
This was a inspection survey of LOFT REHAB & NURSING OF CANTON on August 22, 2024. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LOFT REHAB & NURSING OF CANTON on August 22, 2024?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.