Inspection·March 12, 2024

F 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to process orders for an Iron medication for one (R1) of three residents reviewed for medications in a sample of six. Residents Affected - Few Findings include: Facility Physician/Practitioner Orders, dated 12/13/22, documents, For physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: If not the Attending, call the attending physician to verify the order. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. For physician/practitioner orders received via telephone, the nurse will: Document the order on the physician order form, noting the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. If not the Attending, call the attending physician to verify the order. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. R1's physician orders document Iron Folate-F Oral Capsule (Iron Combinations) give 325 mg/milligrams by mouth, active on 2/23/2024 8:00 AM. R1's medical record has no other documentation R1 was given Iron in November 2023, December 2023, January 2024, or February 2024 until R1 received Iron Folate on 2/23/24. On 3/6/24 at 12:40pm, V4, NP/Nurse Practitioner for a cancer center stated, I ordered (R1's) Iron back in November 2023. I faxed the nursing home the new order and confirmed with a nurse the order was received. At (R1's) December 2023 appointment his current orders did not have his Iron listed on his medication list. I reached out to the nursing home and faxed another order. At (R1's) February 2024 appointment, his current orders did not have Iron list on his medication list. I faxed the nursing home and confirmed with a nurse the order was received. On 3/12/24 at 1:48 PM, V1, Administrator, verified R1 did not have Iron listed on his current medication orders until February 23, 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 2 of 4 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 145647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of Peoria, The 1500 West Northmoor Road Peoria, IL 61614 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 0691 Level of Harm - Minimal harm or potential for actual harm Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on interview and record review, the facility failed to obtain orders/cares for a colostomy for one (R2) of one residents reviewed for colostomies in a sample of five. Residents Affected - Few Findings include: Online Wound, Ostomy, and Continence Society Article, undated, documents, General maintenance care of a Colostomy is needed daily. R2's admit diagnosis, dated 2/14/24, documents, COLOSTOMY STATUS. R2's February 2024 physician orders has no documentation for R2's Colostomy cares. R2's nurses notes, dated 2/14/2024 at 9:24pm by V10, LPN/Licensed Practical Nurse, documents, Resident (R2) arrived to the facility via transport. Family arrived shortly before resident, delivering numerous medical supplies for Colostomy care. On 3/6/24 at 12:23pm, V3, R2's Power of Attorney/POA, stated, (R2) was admitted to (nursing home) in February 2024 with her colostomy. (R2) was in the hospital and got her colostomy on January 7 2024. On 3/12/24 at 1:48pm, V1, Administrator, verified R2 did not have any orders for R2's Colostomy. During this survey, V1 was asked on two separate occasions to provide a Colostomy policy, and was unable to provide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 3 of 4 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 145647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of Peoria, The 1500 West Northmoor Road Peoria, IL 61614 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 have sufficient oxygen for a doctor appointment, and failed to have oxygen orders for two (R1 and R3) of three residents reviewed for oxygen in a sample of five. Residents Affected - Few Findings include: Facility Oxygen Administration, dated 5/10/21, documents, Oxygen is administered to residents who need it. Oxygen is administered under orders of a physician. 1. R1's current physician orders documents an order from 10/16/23 for Oxygen 2 liters nasal cannula. On 3/6 /24 at 10:00 AM, R1 stated, I went to the (doctor appointment) and used their oxygen because I ran out, and was transferred back to the nursing home with no oxygen. My tank was empty. At that same time, R1 was wearing portable oxygen by nasal cannula and was alert and oriented. On 3/6/24 at 12:40pm, V4, NP/Nurse Practitioner for a cancer center, stated, (R1) is on oxygen, came to his appointment with a partial tank, we were not running behind. (R1) ran out of oxygen and used ours, his transport driver was aware he was out of oxygen. we disconnected him from our oxygen, and then he was taken back to the nursing home. On 3/7/24 at 10:40 AM, V6, CNA (Certified Nurse Aid)/Transport, stated, (R1) was transported by me on 2/22/24. I drove him to his doctor appointment. I did not come get more oxygen from the nursing home, and he wears oxygen all the time. 2. On 3/6/24 at 9:30 AM, R3 was in the front lobby, alert and oriented, with portable oxygen on via nasal cannula. On 3/7/24, R3's corded oxygen machine had a humidity bottle that was empty, and nasal cannula that was dated 1/29/24. R3 verified he wears the oxygen on the corded oxygen machine at night, but uses the portable oxygen during the day when up and about. R3's medical record documents R3 was admitted on [DATE] with the following diagnosis: COPD/Chronic Obstructive Pulmonary Disease. On 3/12/24 at 1:48pm, V1, Administrator, verified R3 did not have any orders for R3's oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 4 of 4