Inspection·December 22, 2022

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure quarterly MDS (Minimum Data Set) assessments were completed and submitted within the required time frame for six of 50 residents (R34, R94, R63, R62, R26, R11) reviewed for timing of MDS assessments in a sample of 50. Residents Affected - Some Findings include: A Resident Assessments Instrument under Quarterly assessment dated 10/2019 states, The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date), or Assessment Reference Date plus 14 days. The facility MDS Analysis dated 11/21/22, documents Due to increased census on both MED A stays and public aid, there has been an increase in MDS's needing to be completed and some of them have fallen behind in submission timeliness. There is a back log of MDS's that still need to be caught up. Social Services is new to the roll, as well as activities and dietary manager, therefore there has been a lot of the completion done solely by MDS, therefore making some assessments late. 1. R34's Quarterly MDS assessment section A2300 documents R34's assessment reference date for that MDS was 10/14/22. This same MDS section Z0500 documents R34's MDS was not completed until 12/15/22. 2. R94's Quarterly MDS assessment section A2300 documents R94's assessment reference date for that MDS was 10/10/22. This same MDS section Z0500 documents R94's MDS was not completed until 12/19/22. 3. R63's Quarterly MDS assessment section A2300 documents R63's assessment reference date for that MDS was 11/08/22. This same MDS section Z0500 documents R63's MDS was not completed until 12/21/22. 4. R62's Quarterly MDS assessment section A2300 documents R62's assessment reference date for that MDS was 11/04/22. This same MDS section Z0500 documents R62's MDS was not completed until 12/21/22. 5. R26's Quarterly MDS assessment section A2300 documents R26's assessment reference date for that MDS was 11/08/22. This same MDS section Z0500 documents R26's MDS was not completed until 12/21/22. On 12/21/22 at 1:17p.m. V3 (MDS Coordinator) verified the MDS section A2300 ARD dates and the MDS section Z0500 completion dates for R34, R94, R63, R62, R26's Minimum Data Set assessments. V3 verified none of these assessments were completed within the required 14 days following the ARD dates. 6. R11's admission MDS (Minimum Data Set) assessment was dated 8/16/22. R11's Quarterly was due 11/16/22. There were sections completed on the Quarterly by V3 (MDS Coordinator) dated 11/23/22, V10 (Social Services) dated 11/29/22, and was signed as completed by V18 (Assessment Coordinator) on 12/20/22. On 12/20/22 at 1:30 PM, V3 (MDS Coordinator) verified that R11's assessment was late being done. V3 was asked why the assessment was late and V3 stated No specific reason. On 12/21/22 at 10:55 AM, V1 (Administrator) stated that the reason some residents' MDS's were not completed on time was because the facility's resident census was high and there was only one MDS Coordinator until September 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 2 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement services to maintain and/or improve range of motion limitations for three of seven residents (R7, R80, R88) reviewed for limited range of motion in the sample of 50. Findings include: The facility's Rehabilitation Contracture Management policy dated 3-1-21 documents, It will be the standard that the facility must ensure that a resident with a limited range of motion receives appropriate treatment to increase range of motion and/or prevent further decrease in range of motion. A resident with limited mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Guidelines: 1. Recognition of a limited range of motion or changes in mobility must be reported to rehabilitation services. The specific joint that has limitation should be indicated. 1. R7's MDS (Minimum Data Set) assessment dated [DATE] documents R7 is cognitively intact and has functional limitations in range of motion to both sides of the lower extremities. This same MDS documents R7 does not receive restorative nursing programs such as passive or active range of motion, or splint assistance. R7's Electronic Tasks Nursing Restorative documents, Active ROM (Range of Motion) - Position upright, provide visual demonstration of flexion/ extension exercise then cue (R7) to complete five sets of 10 flexion & extension of both knees & elbows BID (twice daily) to maintain joint mobility. On 12/19/22 at 10:16 AM R7 was sitting up in a high back wheelchair. R7 was unable to lift her arms above chest level and both of R7's pinky fingers were contracted. R7 was unable to open either of her pinky fingers. R7 stated, I have not had any (range of motion) exercises or therapy done with me since April if this year. I would love for staff to do range of motion exercises with me. 2. R80's MDS assessment dated [DATE] documents R80 is cognitively intact and has functional limitations in range of motion to both sides of his upper and lower extremities. This same MDS documents R80 does not receive restorative nursing programs such as passive or active range of motion, or splint assistance. R80's Current Care Plan documents R80 has diagnoses of Parkinson's Disease, Morbid Obesity, Abnormalities of Gait and Mobility, Pain in right and left shoulders, and Disc Degeneration of the Lumbar Region. R80's current Electronic Tasks document, Nursing Rehabilitation Active Range of Motion: (R80) will perform with verbal cues and encouragement to complete three sets of 15 to bilateral upper extremities elbow flexion and extension and bilateral lower extremities knee flexion and extension. On 12/19/22 at 10:25 AM R80 was sitting in a wheelchair in his room. R80 was unable to lift his arms up above chest level. R80 stated, I cannot raise my arms up very far. I have not had therapy or range of motion exercises since September (2022). I would love for staff to do range of motion with me. The staff do not help me do range of motion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 3 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. On 12/21/22 at 10:15 AM, R88 was sitting in her room in a wheelchair with V19/R88's daughter. V19 stated (R88) needs assistance of staff for all ADL's (Activities of Daily Living) and has limitations in ROM to both her legs. R88's MDS assessment dated [DATE] documents R88 has a BIMS (Brief Interview of Mental Status) of 03, (cognitively impaired), has limitations in range of motion to her lower extremities, and does not receive range of motion services to address R88's limitations. R88's electronic medical records do not include any programs or documentation of R88 receiving ROM to R88's lower extremities or at all. On 12/21/22 at 10:15 AM, V19/R88's daughter stated, I am here with (R88) everyday all day. (R88) does have limitations to both her legs. I have never seen any staff do any kind of ROM with (R88). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 4 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation and interview the facility failed to ensure urinary catheter tubing was kept off the floor for one of one resident (R75) reviewed for urinary catheter in the sample of 50. Residents Affected - Few Findings include: On 12/19/22 at 11:40 AM R75 was sitting in his wheelchair with this catheter bag attached under the wheelchair seat. R75's catheter tubing was laying on the floor. V4 COTA (Certified Occupational Therapy Assistant) entered R75's room and transported R75 in his wheelchair from his room to the therapy room. During transport R75's catheter tubing was dragging on the floor. On 12/19/22 at 12:15 PM V4 transported R75 in his wheelchair from the therapy room to the dining room. During transport, R75's catheter tubing was dragging on the floor. On 12/19/22 from 12:15 PM through 12:50 PM R75 was sitting in his wheelchair in the dining room. R75's catheter tubing was laying on the floor during this time. On 12/21/22 at 9:20 AM V1 (Administrator) stated, All catheter tubing should be off of the floor at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 5 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to offer hydration during lunch for two of two residents (R75, R76) reviewed for hydration in the sample of 50. Residents Affected - Few Findings include: The facility's Hydration policy dated 3-5-21 documents, Standard: Residents' hydration needs are met throughout the day from various sources. A major portion of the total fluids consumed is provided at mealtimes, either in a dining room setting or on trays served in the rooms or common areas, as preferred. 1. R75's current Care Plan documents, (R75) has potential fluid imbalance related to diuretic use. (R75) will have adequate fluid volume balance, good skin turgor, pink and moist mucous membranes, and sufficient fluid intake through next review. Encourage fluid intake. On 12/19/22 at 12:15 PM V8 (Licenses Practical Nurse/LPN) served R75 his meal tray. R75 was not served any fluids at this time. While eating, R75 was not offered any fluids. At 12:40 PM R75 finished eating and was still not offered any fluids. On 12-19-22 at 12:45 PM R75 stated, I would have liked to have had something to drink while I was eating. A lot of times when I come to the dining room late, I do not get offered a drink. On 12-19-22 at 12:50 PM V8 stated, I do not know why (R75) was not given anything to drink. 2. On 12/20/22 at 12:10 PM, R76 was given his lunch, but was not given a drink. At 12:16 PM, V12 (Activity Assistant) asked R76 if he would like a cup of coffee or cranberry juice. R76 shook his head yes. V12 went back to the drink cart but did not return with a drink for R76. On 12/20/22 at 12:35 PM, V12 was asked if there was a reason R76 did not get a drink with his meal. V12 stated (R76) was given coffee during activities. V12 then went to R76 and gave him a cup of coffee. R76 immediately started drinking the coffee. On 12/20/22 at 12:45 PM, R76 was asked if he likes to have his drink at the start of his meal and he shook his head yes. R76's current Care Plan documents, (R76) has potential for fluid imbalance r/t (related to) Cognitive deficit, Poor intake and terminal prognosis. On 12/21/22 at 9:20 AM, V1 (Administrator) was asked if she thought the residents should have a drink when they got their meals. V1 stated Yes, that's why we have the drink cart that can be taken around the dining room. That way the residents can be given their drink when they get to the table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 6 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide three meals a day on dialysis treatment days for one of one resident (R98) reviewed for dialysis in the sample of 50. Residents Affected - Few Findings include: The facility's Hemodialysis Policy revised 3/27/21, documents, It will be the standard of this facility to provide the necessary care and services to those residents receiving hemodialysis while a resident is at the facility. If the resident requires a meal to be sent with them to the dialysis center, one shall be provided by the facility. R98's current electronic Hemodialysis plan of care documents, Dialysis three times a week, Tuesday, Thursday, and Saturday at 10:45 AM. Resident goes out to Dialysis. Check with nurse for the schedule and assist the resident to be ready to go on time. A bag lunch may be needed, help to be sure the resident has it with them. On 12/21/22 at 10:50 AM, R98 stated, I receive dialysis on Tuesday, Thursday, and Saturday. We leave the facility between 9:30-9:45 a.m. My dialysis starts at 10:45, and I normally get back to the facility at about 2:20-3:30 PM. The facility doesn't send lunch/food with me. I would like to have a sandwich, or something sent with me so I can eat something on my way or on my way back to the facility. On 12/21/22 at 11:45 AM, V20/Dietary Manager stated, We get a list of Dialysis residents. All morning residents get their breakfast early before they leave. We do not send a lunch or snacks with any residents that have later Dialysis, I don't even have anyone listed that leaves later. On 12/22/22 at 11:30 AM, V1 (Administrator) stated, We've never sent any food with the residents to dialysis since the dialysis center doesn't allow food to be ate there, but we will start sending snacks/sandwiches on the transportation van. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 7 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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. Based on observation, interview, and record review, the facility failed to document target behaviors to warrant the use of an antipsychotic and perform a GDR (Gradual Dose Reduction) for one of five residents (R8) reviewed for antipsychotics in the sample of 50. Findings include: The facility's Psychotropic Medications policy, dated 3/27/21, documents, Residents will only receive psychotropic medications (anti-psychotic, anti-anxiety, antidepressant, hypnotic or other drugs that result in similar effects, not including opioids) when necessary to treat specific conditions for which they are indicated and effective. Nursing staff will document in the medical record an individual's target symptoms. On 12/19/22 at 10:52 AM, R8 was alert lying in bed watching tv and looking at Christmas cards. R8 was short with answering questions but otherwise pleasant. R8's Physician's orders, dated 12/21/22, document that R8 has an order to receive Zyprexa (antipsychotic) 5 mg (milligrams) by mouth daily for agitation and crying related to Schizoaffective disorder and Bipolar disorder. R8's Pharmacy Recommendation, dated 4/4/22, documents that R8's Physician declined the pharmacy's recommendation to decrease R8's Zyprexa with the rational of: R8 continues to have signs/symptoms of agitation and anxiety. Continued use is in accordance with current standards of practice and a reduction would likely impair resident's function or exacerbate the psychiatric disorder and therefore is clinically contraindicated. R8's Psychoactive Medication Informed Consent, date 4/12/22, documents that R8 is receiving Zyprexa 5 mg daily for the diagnoses of Bipolar and Schizophrenia Affective Disorder. The consent also documents that the target behaviors for the use of R8's Zyprexa is agitation and crying. R8's Care plan, dated 9/15/22, documents, R8 continues to exhibit inappropriate and maladaptive behavior at times. Symptoms include engaging in deceitful practices such as confabulation-making up stories, lying, dishonesty for perceived personal gain, sabotaging personal relationship with roommate to elude having one. History of using others personal items without permission, attention seeking, gossiping. R8's Care plan also documents, R8 uses psychotropic medications antipsychotic, anti-depressant related to Bipolar Disorder, Depression for agitation and crying. R8's Pharmacy Recommendation, dated 9/16/22, documents a recommendation to decrease R8's Zyprexa. The recommendation has no follow up physician signature declining or accepting the pharmacist's recommendation. R8's Social Services Progress Note, dated 9/30/2022 at 11:33 a.m, documents, The Social Services Director met with R8 to complete the Quarterly Note and to review the advanced directives in place. Resident was alert and oriented and able to make needs known. Resident was cooperative, pleasant, and communicative. Resident has not experienced any significant changes to her mood and/or behaviors this quarter, which is noted by current PHQ-9 score of 02. The previously recorded score was also 02. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 8 of 9 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 145646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611 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 R8's MDS (Minimum Data Set) assessment, dated 10/5/22, documents that R8 does not have any behaviors including indicators of psychosis and that R8 received seven days of an antipsychotic medication with no GDR being attempted. R8's Nurse Practitioner progress note, dated 12/5/22, documents, Review of symptoms: Psychiatric/Behavioral: negative for agitation, behavioral problems, and sleep disturbance. R8 is not nervous/anxious. Physical exam: Psychiatric: Mood and affect: Mood normal. R8's Clinical Physician orders, dated 12/20/22, document that R8 has been receiving Zyprexa 5 mg by mouth daily since 4/12/21. R8's MARs (Medication Administration Record), dated 10/22, 11/22, and 12/1-12/20/22, document that R8 had no behavioral episodes during the time span of 10/1-12/20/22. On 12/21/22 at 01:33 PM, V13 (Licensed Practical Nurse) stated, (R52) is Bipolar and gets very anxious and worried and then she will mellow out. She will cycle with those behaviors. She is very OCD (Obsessive Compulsive). She never wants anyone touching any of her belongings. She is very manipulative and convincing. I don't think any of her behaviors put her or others at risk for injury. She is very set in her ways. During the interview, R8 self-propelled herself to the nurses' station, and had a conversation with V13. R8 was pleasant and smiling not displaying any behaviors. On 12/21/22 at 1:36 p.m., V6 CNA (Certified Nursing Assistant) stated, (R8's) only true behaviors I'm aware of are attention seeking. If she notices staff taking care of another resident and she thinks she needs the attention she will turn her call light on to get a staff member in her room. I don't feel like she puts herself or others at risk for harm. She just wants attention. On 12/21/22 at 1:40 p.m., V15 CNA stated, The only think I can think of that (R8) does is wanting staff attention all the time. Nothing that she would hurt herself. On 12/21/22 at 02:56 PM, V1 (Administrator) confirmed that (R8's) Zyprexa has not been decreased since it was started. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 9 of 9