Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to verify code status, failed to follow up on advanced
directives, and failed to have the current paperwork on advanced directives for one (R1) of three residents
reviewed for advanced directives in a sample of seven.
Findings include:
R1's medical record documents R1 is a full code as of [DATE].
R1's medical record, dated [DATE] by V18 APRN/Advanced Practice Registered Nurse, documents
Recommend hospice and DNR/Do Not Resuscitate.
R1's Medical Record documents R1 was admitted to hospice on [DATE] due to her diagnosis of End Stage
Multiple Sclerosis and was not cognitively intact.
R1's nurses note, dated [DATE] by V6 LPN/Licensed Practical Nurse, documents Packet filled out and
forwarded to state guardian for (R1). Guardian called and noted sections left blank. Forwarded packet to
hospice to be filled out by MD/Medical Doctor and forwarded back to the facility to be forwarded to (R1's)
state guardian. Packet is consent to change from full code to DNR status. (R1) remains full code at this
time.
R1's medical record has no documentation of the information sent to R1's OSG/Office of State Guardian.
R1's nurses notes, dated [DATE] at 4:00am by V13 RN/Registered Nurse, documents This nurse called to
bedside by CNA/Certified Nurse Aid at 1:25am; resident without pulse, respiration and cool to touch;
second RN called to pronounce at 1:30am; hospice notified at 1:40am; coroner called at 1:42am; funeral
home notified at 2:05am; and body released to funeral home at 3:40am.
R1's medical record has no documentation CPR/Cardiopulmonary Resuscitation was performed on R1.
On [DATE] at 10:56am, V15 RN Administrator of Hospice stated I thought (R1's) DNR form filled out and
filed with (R1's) OSG made her a DNR but she was a full code because it was not signed by the judge. We
were working on a document with the guardian, but the guardian was not able to take it to court prior to the
resident's death. My hospice nurse got the call (R1) had passed, my hospice nurse called me for
clarification on her code status, and she was a full code. I looked thru (R1's) form, she was a full code, and I
told the nursing home to do CPR. The nursing home did not have the
(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 3
Event ID:
145646
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
02/01/2024
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
paperwork for the OSG, we had at our office which is why the hospice nurse did not know her code status
and had to call me. When the hospice nurse got to the facility she was told they had (R1) listed as a full
code, (R1's) guardian would not make her a DNR without a Judge's order so the hospice nurse called me
for clarification.
R1's OSG DNR paperwork, filled out on [DATE] by the physician, and provided to this state department by
V15 RN Administrator of Hospice has no documentation of R1's OSG consent for DNR or withdrawal of
treatment.
On [DATE] at 12:25pm, V13 RN stated (R1) was hospice but was a full code. She was not changed to a
DNR by the judge. I missed it and did not do CPR. We have a yellow notebook at the nurse's station that
has the code status forms in case the power goes out. (R1's) code status was in the computer under her
name and in the computer in the miscellaneous part of (our charting system). I called the hospice nurse
when (R1) passed. (R1's) DNR paperwork was filled out for the OSG but not signed by the Judge. Hospice
called her supervisor for clarification since she had the paperwork with her, we did not have it here.
On [DATE] at 12:40pm, V2 DON/Director of Nursing stated (V13 RN) did not perform CPR on (R1) and was
disciplined with a final written reprimand. (V13) had never been disciplined before. (V13) assumed (R1) was
a DNR because she was hospice and did not follow the full code orders. We sent the paperwork to the
OSG on [DATE]th, 2023, but (R1) died before it could go before the judge and get the DNR. Usually, it takes
less than one week for the judges signature and the code status is done. We did not have time to follow up
on her form with the holidays. (R1) was a full code when you pulled the electronic face sheet on (R1). (R1)
could not talk for herself at the time of her death which is why she had an OSG.
V13's employee file, dated [DATE], documents Disciplinary Action Form 3rd/final written reprimand- did not
follow nursing guidelines, failed to verify a resident code status, and no prior discussion or warnings.
Employee educated and stated she missed verifying (R1's) code status.
Facility Residents' Rights Regarding Treatment and Advanced Directives, revised [DATE], documents It is
the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue
medical or surgical treatment and to formulate an advanced directive. The advance directive will be added
to Physician Orders. The copy of the form will be scanned into the resident record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145646
If continuation sheet
Page 2 of 3
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
02/01/2024
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 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
interview and record review, the facility failed to obtain an order for catheter care upon admission for one
(R3) of two residents reviewed for indwelling urinary catheters in a sample of seven.
Findings include:
R3's medical record documents R3 was admitted to the facility on [DATE] with a diagnosis of traumatic L4
compression fracture and urinary retention. R3's medical record documents R3 was at the facility for pain
management, indwelling urinary catheter care, and weakness.
R3's medical record has no documentation R3 received catheter care from 12/23/23 through 12/28/23.
R3's Physician's orders, dated 12/28/23, documents R3's catheter care was to be conducted every day
shift, to start on 12/29/23, and discontinued on 1/10/24.
R3's Treatment Administration Record/TAR, dated December 2023, documents catheter care was started
on 12/29/23.
On 1/31/24 at 3:00 PM, V2 DON/Director of Nursing stated R3's physician order for catheter care was not
obtained until 12/28/23 due to R3 being admitted on a weekend and the holiday followed. V2 verbally
agreed catheter cares were not documented as completed until 12/29/23 and did not know why the
admitting nurse did not put in orders upon R1's admission for catheter care.
Facility Catheter Care policy, dated 1/24/23, documents The facility will ensure that residents with indwelling
catheters receive appropriate catheter care per standard of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145646
If continuation sheet
Page 3 of 3
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Back to topCitations
2 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.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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.
FAQ · About this visit
Common questions about this visit
What happened during the February 1, 2024 survey of LOFT REHAB OF EAST PEORIA, THE?
This was a inspection survey of LOFT REHAB OF EAST PEORIA, THE on February 1, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LOFT REHAB OF EAST PEORIA, THE on February 1, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.