Inspection·October 25, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to revise a care plan to include a specific dialysis access site, and which arm to use for blood pressure monitoring for two (R36 and R103) of 24 residents reviewed for care plan revision in a sample of 36. Findings include: Facility Care plan revisions, revised 1/25/23, documents The care plan will be reviewed and revised as necessary. The designated staff member will communicate care plan interventions to all staff involved in the resident's care. 1. R36's Physician orders for October 2024 documents (Dialysis) Shunt is in left arm. On 10/24/24 at 1:48 PM, R36 was in her room in bed on her left side, and stated her dialysis shunt was in her left arm. R36's current care plan has no documentation where R36's dialysis shunt is located, and which arm to use for blood pressure monitoring. 2. R103's Physician orders for October 2024 documents Dialysis site observation in right chest port. R103's current care plan has no documentation where R103's dialysis shunt is located, and which arm to use for blood pressure monitoring. On 10/24/24 at 11:59 AM, V18 care plan nurse verified R36 and R103's care plans did not identify where their dialysis shunts were located, and which arm to use for blood pressure monitoring. 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 10/25/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow physician orders for one (R18) of three residents reviewed for antibiotic orders in a sample of 36. Residents Affected - Few Findings include: Facility's Physician/Practitioner Orders Policy Dated 12/13/22 documents: 2. For physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. R18's 10/4/24 Physician Order documents: Doxycycline Hyclate (Vibramycin) (Antibiotic) 100 mg/milligrams tablet. Take one Tablet (100mg/milligrams total) by mouth two times daily for ten days x seven days due to UTI/Urinary Tract Infection. R18's Medication Administration Record/MAR dated 10/2024 does not document R18 was administered Doxycycline Antibiotic until 10/7/24. R18's Progress Note dated 10/4/24 documents: Resident returns to facility via facility van. New orders obtained per (Local Facility) health family medicine-(City). Order states take one tab (100mg total) Doxycycline Hyclate by mouth two times daily for 'ten days x seven days' due to UTI/Urinary Tract Infection. On 10/25/24 at 7:55am, V13 Power of Attorney/POA to R18 stated: (V10 Primary Care Physician to R18) prescribed antibiotics for (R18). I talked to the Director of Nursing/DON (V2) about the antibiotic and why it was not started on 10/4 and she said the facility did not follow through on that one. On 10/23/24 at 9:55am V7 Licensed Practical Nurse/LPN stated that she did not start R18 on the prescribed antibiotic after receiving the order from R18's Primary Care Physician on 10/4/24, and stated that the antibiotic was not administered until 10/7/24. 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 10/25/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two large trash dumpsters are secured from flying birds/insects and other small animals/rodents, in that the lids of the trash dumpsters were not closed. This failure has the potential to effect all 117 residents residing in the facility. Residents Affected - Many FINDINGS INCLUDE: Facility Policy, entitled Standards and Guidelines: Garbage Dispose and Refuse, revised 3/4/2021, document: 4. will ensure the garbage storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 10/22/2024, document 117 residents reside in the facility. On 10/22/2024, at 9:00 a.m., during the initial kitchen tour, with V17/Dietary Manager, the two trash dumpsters, located outside, had lids which were open and both dumpsters had facility trash in them. On 10/22/2024, at 9:00 a.m., V17 confirmed the trash dumpster lids should have been closed. 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 10/25/2024 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 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** Based on observation, interview and record review the facility failed to don proper personal protective equipment during gastronomy tube medication administration for one of one residents (R50) reviewed for Enhanced Barrier Precautions in a sample of 36. Residents Affected - Few Findings include: The facility's Enhanced Barrier Precautions policy, dated 1/1/24, documents Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order foe enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (Multidrug-Resistant Organisms). High-contact resident care activities include: Device care or use; central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. The facility's Care and Treatment of Feeding Tubes policy, dated 12/19/22, documents It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Direction for staff on how to provide the following care will be provided: Use of infection control precautions ad related techniques to minimize the risk of contamination. R50's admission record documents that R50 admitted to facility on 7/6/21 with diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. R50's current physician's orders documents isolation: maintain enhanced barrier precautions per Centers for Disease Control (CDC) guidelines every shift for prophylaxis related to gastronomy tube (G-Tube/GT). R50's Minimum Data Set assessment (MDS) dated [DATE], documents that R50 has a feeding tube. On 10/23/24 at 11:00 AM V5 (Licensed Practical Nurse/LPN) performed hand hygiene, donned gloves, and proceeded to administer medications via gastronomy tube (G-Tube/GT). On 10/23/24 at 11:30 AM V5 (LPN) verified that R50 is on enhanced barrier precautions due to her G-Tube. V5 also verified she should have worn a gown with the gloves while administering G-Tube medications but realized she forgot to after administration of the G-Tube medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145646 If continuation sheet Page 5 of 5