Inspection·January 11, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide privacy during incontinence care for one of four residents (R110) reviewed for personal care, in a sample of 49. Residents Affected - Few Findings Include: The facility policy, Promoting/Maintaining Resident Dignity, dated (revised 12/5/22) directs staff, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy. On 1/8/24 at 10:48 A.M., V5/Certified Nursing Assistant (CNA) was providing incontinence care for R110, who resides in a bed closest to the 200 hall, in the facility. R110 was lying on the top of the bed fully unclothed, while V5/CNA applied an incontinence brief. The privacy curtains for R110's bed were open. R110's roommate was present, watching television, in direct view of R110. The room curtains, that open to the front visitor, staff and vendor parking lot, were open. V5/CNA continued to apply the incontinence brief and then a gown to R110, in full view of R110's roommate, and visitors and staff in the parking lot. When V5/CNA completed dressing R110, V5/CNA left the room. At that time, V5/CNA verified the privacy curtain for R110, and the room curtains were left open during incontinence care and dressing of R110. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 2 of 5 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 01/11/2024 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 a restorative program and provide range of motion for two residents (R24, R64) of five residents reviewed for limitations in range of motion in a sample of 49. Findings include: The facility's Activities of Daily Living policy revised 12/5/22, documents that the facility will provide a maintenance and restorative program if indicated to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 1. On 1/8/24 at 10:30 am R64 was lying in bed. R64's right hand appeared contracted, and her right arm was edematous (swollen). R64's right arm was resting on the bed. On 1/8/24 at 10:30 am R64 was up in the chair, with her right arm lying in her lap and no splint on. R64's current Physician Order Sheet documents R64's right arm is to be elevated at all times. R64's Occupational Therapy evaluation and plan of treatment, dated 10/4/23, documents the R64 will consistently have right upper extremity splint donned for four to six hours per day. This form documents that R64 is currently not wearing the right upper extremity splint due to lack of follow through from the Certified Nursing Assistants. R64 will increase her right upper extremity shoulder and wrist extension passive range of motion for flexion. R64's current care plan documents that R64 has a self-care/mobility deficit and requires staff assist for completion of all activities of daily living. This form documents that R64 is to participate in passive range of motion exercises for preservation of range of motion to bilateral knees and elbows as tolerated. R64's care plan documents to provide restorative programs/interventions as ordered/indicated. 2. On 1/8/24 at 11:00 am, R24 stated that he does not get assistance with range of motion or exercises. R24's Minimum Data Set, dated [DATE], documents an impairment of both sides of upper and lower extremities. This form also documents that R24 has not received any therapies or range of motion services. R24's current care plan documents that R24 has an activity of daily living self-care deficit. This form documents that R24 is dependent for activities of daily living. On 1/9/24 at 12:00 pm, V2, Director of Nursing, stated that the facility does not have a restorative program at this time. V2 stated that the Certified Nursing Assistance are supposed to do range of motion during any cares. On 1/11/23 at 11:30 am, V2 stated that no documentation of range of motion or restorative notes could be found in R24 or R64's medical record. On 1/11/24 at 12:00 pm, V5, Minimum Data Set Coordinator, stated that the facility does not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 3 of 5 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 01/11/2024 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 restorative programs at this time. V5 also stated that the Certified Nursing Assistance are not allowed to perform passive range of motion on residents with contractures, because of possible injury. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 4 of 5 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 01/11/2024 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on record review and interview the facility failed to offer bedtime snacks to two of 24 residents (R61 and R274) reviewed for bedtime snacks in the sample of 49. Findings include: The Nourishment Night-Time Snacks policy dated 12-5-22 documents, Nourishments will be provided to the clients at approximately bedtime. Food and nutrition services will deliver the bedtime nourishment (snack) as planned on the cycle menu to the nursing units after the evening meal. Clients will receive an appropriate bedtime snack according to their diet order. Nursing will distribute the bedtime nourishments. 1. R61's Order Summary Sheet dated 1-22-24 documents R61 has the diagnoses of Mild Protein-Calorie Malnutrition, Dysphagia, Hemiplegia, and Hemiparesis. R61's Medical Record does not include any documentation of R61 being offered bedtime snacks. On 01-08-24 at 01:37 PM V19 (R61's Family Member) stated, (R61) does not get offered bedtime snacks, cannot get up to get them on his own and cannot ask for them. 2. R274's Order Summary Report dated 1-11-24 documents R274 has diagnoses of Severe Protein-Calorie Malnutrition and Type II Diabetes Mellitus. R274's Medical Record does not include any documentation of R274 being offered bedtime snacks. On 01-08-24 at 11:04 AM R274 stated, I am diabetic and would like a bedtime snack. They do not offer bedtime snacks to me. On 1-11-24 at 9:30 AM V2 (Director of Nursing) stated, All residents should be offered a bedtime snack. There is no documentation in (R61 and R274's) records indicating they were offered bedtime snacks. On 1-11-23 at 9:45 AM V6 (Dietary Manager) stated, I do not know if all of the residents are being offered a bedtime snack. I do not believe residents being offered bedtime snacks is documented anywhere in their medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 5 of 5