Inspection·April 30, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an injury of unknown origin to the State Agency for one resident (R1) of three residents reviewed for falls. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated/revised 12/5/22 documents: 6.) Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: c.) Physical injury of a resident, of unknown source. Physician Order Summary Report dated 4/2024 indicates R1 was [AGE] years old with diagnoses that include Long Term/Current Use of Anticoagulants, Personal History of Venous Thrombosis and Embolism, Unspecified Rotator Cuff Tear or Rupture of Left/Right Shoulder, Pain in Left Shoulder. Had been receiving Coumadin (anticoagulant) 2mg (milligrams) MAR (Medication Administration Record) indicates R1 received Coumadin (anticoagulant) 2mg (milligrams) in the evening for Afib (Atrial Fibrillation). Incident Report dated 4/19/24 at 5:25pm indicates R1 was sent to the Emergency Department due to swollen left breast. Report indicates left breast area was hard, no redness or warmth.; no discoloration noted. R1 had been complaining of left arm pain. Report/Resident Description indicates I haven't fallen or had any issues. It just started hurting more after my shower. Report indicates R1 had been on long-term anticoagulant therapy. Incident Report Notes dated 4/22/24 indicates only incident for R1 was a fall that occurred on 4/10/24. Note indicates an X-ray and doppler of R1's ankle was performed after R1's fall with negative results for both tests. Incident Report note dated 4/22/24 indicates Nurse notified physician of increased edema and family's request to have R1 sent to hospital for evaluation. Progress Notes dated 4/19/24 at 6:50pm indicates R1 was transported to the hospital at that time. (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 04/30/2024 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)