Inspection·August 23, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, record review, and interview, the facility failed to provide readily available grievance forms, and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 89 residents residing in the facility. Findings include: The facilities CMS (Centers for Medicare and Medicaid services) Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 8/20/24 and signed by V1/Administrator, documents 89 residents currently reside within the facility. The facility's Resident/Family Grievance Policy and Procedure, dated 5/6/24, documents, Policy Explanation and Compliance Guidelines: 1. Social Services Director has been designated as the Grievance Official. 3. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. 7. Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: a. The contact information of the grievance official with whom a grievance can be filed, including his or her name, business address (mailing and email) and business phone number. C. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance. On 8/21/24 at 10:20 am during resident council meeting, R19, R34, R45, R55, and R77 all stated they do not know where or how to file a grievance. On 8/22/2024 at 2:45 pm, a tour was conducted with V1/Administrator, asking V1 to show where the grievance forms are located for the residents and where prominent location(s) are for the grievance procedure in the building. V1 verified there was not a posted grievance procedure in any prominent locations around the building, and no grievance forms readily available for the residents that she is aware of. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 2 of 15 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 08/23/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to provide written notification of transfer to the hospital to a resident's representative (R8) and failed to notify the facility Ombudsman of resident Discharges/Transfers monthly for three residents (R8, R65, R84) of four reviewed for discharges in the sample of 33. Findings include: 1. R65's Social Service Note, dated 8/6/24 at 3:07 pm, documents R65 was accepted to a new facility. R65 will be picked up on 8/10/24 at 8:00 am. Please have R65 ready. R65's Face Sheet, printed 8/22/24, documents R65 was discharged on 8/10/24 to another facility. The Admission/Discharge Log, dated 7/10/24 to 8/10/24, does not document R65 was discharged to another facility. 2. R84's Nursing Note written by V12/Licensed Practical Nurse, dated 8/3/24 at 11:36 pm, documents R84 called V12 to his room, and R84 complained of shortness of breath and chest pains. R84's oxygen level was at 88 percent. R84 stated he wanted to go back to the hospital. R84 had just come back from the hospital at 10:30 am. R84 stated he would feel better if he went to the hospital. V12 called for transportation to take R84 to the hospital. R84's Nursing Note, dated 8/4/24 at 8:42 am, documents R84 is in the hospital. R84's Face Sheet, printed 8/22/24, documents R84 was discharged on 8/3/24 to the hospital. The Admission/Discharge Log for 7/10/24 to 8/10/24 does not document R84 was sent to the hospital. On 8/22/24 at 12:55 pm, V2/Administrator in Training stated, (V17/Social Services) was doing the Discharge Report incorrectly. The Ombudsman should have been notified of all residents that were discharged and why they discharged . (V17) will be trained so she knows how to do the report correctly. 3. R8's Progress note, dated 7/18/24, documents R8 was transferred out to the hospital. The facility has no evidence of written notification of transfer to R8's Representative or notification to the Ombudsman. On 8/22/24, at 12:04pm, V2, Administrator in Training/AIT, produced the facility's Admission/Discharge To/From Report, dated 7/1/24 to 8/10/24, that is submitted to the Ombudsman monthly. V2 confirmed this report only documents the residents who went home and does not include R8 or any of the residents who went out to the hospital. On 8/23/24, at 11:30am, V2, AIT, confirmed there is no evidence of written notification of transfer on 7/18/24 for R8's hospitalization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 3 of 15 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 08/23/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital for one of three residents (R8) reviewed for bed holds in the sample of 33. Findings Include: R8's clinical record documents R8 was hospitalized on [DATE]. R8's clinical record does not contain documentation of written notice of the facility bed hold policy. On 8/22/24, at 3:15pm, V1, Administrator, was unable to produce any documentation the facility's bed hold policy was provided to R8 or R8's representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 4 of 15 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 08/23/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to clip nails for one resident (R66), shave three residents (R40, R62, and R137), and shower one resident (R137) for four of four residents reviewed for ADLs (Activities of Daily Living) in the sample of 33. Residents Affected - Some Findings include: The Certified Nursing Assistant/CNA Job Description, dated June 2021, documents the CNAs are to Assist residents with bath functions (i.e. (example) bed bath, tub or shower bath, etc.) as directed. Assist residents with nail care (i.e. clipping, trimming, and cleaning the finger/toenails). (Note: Does not include diabetic residents.) Shave male residents. Keep hair on female residents clean shaven (i.e. facial hair, under arms, on legs) as instructed. The Activities of Daily Living (ADLs) policy, dated 12/5/22, documents, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 1. On 8/20/24 at 11:08 am, R62 was lying in bed. R62 complained he has not been getting his showers or being shaved. R62 had a long grey/white straggly beard and mustache. On 8/21/24 at 12:15 pm, R62 was lying in his bed. R62 still had not been shaved. R62 stated he has not been shaved in over three weeks, and likes to be shaved at least once a week. R62 stated, I have also not been getting my showers twice a week for the last month, nor given a bed bath on the days I don't get a shower. This has been going on for around a month. The staff say they don't have time or have enough staff to get to everyone. I do refuse my showers every once in a while, but not very often, and the staff does not offer me a bed bath instead. On 8/21/24 at 12:20 pm, V7/Licensed Practical Nurse verified R62's beard and mustache were long and straggly. V7 stated, (R62's) beard and mustache is never long like it is now. (R62) likes to be shaved frequently. I don't know why he hasn't been shaved. R62's Skin Monitoring/Shower Review Sheets documents the last shower R62 had was on 8/6/24. R62's electronic Bathing Report, dated 7/31/24 to 8/22/24, documents R62 prefers bathing on Tuesday and Friday Evenings. The report documents R62 was bathed on Friday 8/2, Tuesday 8/6, Tuesday 8/13, and Friday 8/16/24. 2. On 8/20/24 10:32 am , R137 was lying in bed with V9/R137's Family Member by the bedside. V9 asked if the facility was supposed to shave R137 because R137 had not been shaved since he admitted to the facility last week. R137 had a goatee and a mustache, but also had long white whiskers on the sides of his face that were not a part of the mustache or goatee. R137 looked like he had not been shaved in several days. R137 was asked if he wanted to be shaved, R137 stated, Yes, I asked. On 8/22/24 at 11:54 am, V3/Director of Nursing stated showers should be given twice a week, and the resident should be shaved on shower days and when requested. V3 also stated even if a resident has COVID-19 and is in isolation, they should still get a bed bath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 5 of 15 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 08/23/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm On 8/22/24 at 12:06 am, V1/Administrator stated the showers should be documented in the chart, and a Skin Monitoring/Shower Review Sheet should be filled out each time to document skin issues. The Skin Monitoring/Shower Review Sheet should also be filled out if a bed bath if given. V1 verified 8/20/24 was the only Skin Monitoring/Shower Review Sheet for R137.3. On 8/20/24, at 10:10 am, R40 sat in a wheelchair outside of her room with long white chin whiskers. Residents Affected - Some On 8/21/24, at 11:13 am, R40 sat in a wheelchair in the main Dining Room with long white chin whiskers. At this time, R40 stated, I usually pluck them out myself. It bothers me if someone notices them. R40 stated she would like for someone to pluck them out. On 8/22/24, at 1:00 pm, R40 sat in her room with long white chin whiskers. R40's current Care Plan documents: (R40) has an ADL (Activities of Daily Living) self-care performance deficit needs and participation may vary related to recurrent falls secondary to physical deconditioning. This focus has interventions including but not limited to: Resident currently requires assistance with ADLs: .Personal Hygiene: set up help. R40's Minimum Data Set/MDS assessment, dated 8/3/24, documents R40 is moderately cognitively impaired and requires set up or clean up assistance for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). On 8/22/24, at 1:03 pm, V13, Certified Nursing Assistant/CNA, confirmed R40 needed to be shaved. V13 stated the CNAs usually shave residents on their shower days. At this time, V13 checked the shower schedule and stated R40 gets her showers on Wednesday second shift and Saturdays on day shift. V13 stated, (R40) should have been shaved last night. 4. On 8/20/24, at 10:59 am, R66 was in his room with very long fingernails. R66 stated, I don't like them this long. R66's nails are past the pad of his fingers, jagged and sharp. On 8/22/24, at 9:20 am, R66 was in bed with long jagged fingernails. R66's current Care Plan includes, (R66) has an ADL (Activities of Daily Living) self-care performance deficit .Resident presents with residual LUE (Left Upper Extremity) impairments for mobility, gross and fine motor control which limit functional use with interventions including but not limited to Resident currently requires assistance with ADLs - Personal hygiene - supervision. R66's Minimum Data Set/MDS Assessment, dated 6/1/24, documents R66 is cognitively intact and requires supervision or touching assistance for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). On 8/22/24 at 9:26 am, V11, Licensed Practical Nurse/LPN, confirmed R66's nails are very long and they should have been clipped. V11 stated the CNAs (Certified Nursing Assistants) are supposed to clip them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 6 of 15 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 08/23/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident on a mechanically altered diet was provided supervision at meals as ordered for one (R2) of 18 residents reviewed for meal supervision in a sample of 33. Findings include: The facility's Certified Nursing Assistant Job Description, dated June 2021, documents, Food Service Functions: Serve food trays. Assist with feeding as indicated (i.e. cutting foods, feeding, assist in dining room supervision, etc.). The facility's Comprehensive Care Plans policy, revised 1/25/23, documents, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. R2's current Physician Order Sheet/POS documents R2 is on a Regular diet, dysphagia puree texture, honey consistency, and has diagnoses including but not limited to Dementia, Dysphagia, Oropharyngeal Phase, Schizophrenia, and Bipolar Disorder. R2's Minimum Data Set/MDS Assessment, dated 7/24/24, documents R2 is severely cognitively impaired and on a mechanically altered diet. R2's current Care Plan documents Current diet: Regular diet, Regular texture, Nectar Thick Liquids. NO Straws with interventions including but not limited to: Feed self, needs food set up and Supervision with meals. R2's Speech Therapy SLP (Speech Language Pathology) Evaluation and Plan of Treatment, Certification period 7/29/24 - 9/7/24 and start of care date 7/29/24, documents, Current Referral: Reason for Referral/Current Illness: Patient is a [AGE] year old male presenting to speech therapy for an evaluation in swallow function due to recent hospitalization for aspiration pneumonia. Patient received speech therapy services during hospitalization and was recommended a pureed solid/honey thick liquids .Swallow Strategies: Compensatory Strategies/Positions: Upright position for all PO (by mouth) intake, aspiration precautions, supervision with all meals. On 8/20/24, at 12:44 pm, R2 was lying in bed with his head of bed elevated. V8, Certified Nursing Assistant/CNA, placed R2's meal tray in front of him on the bedside table. V8 stated, He had a recent change and is on puree now. I kind of just watch him because of his change. At 12:47 pm, V8 left R2 to eat alone in his room. On 8/22/24, at 3:10 pm, V3, Director of Nursing/ DON, stated, (R2) is always at risk for choking because he's on a modified diet and has trouble ridding of his own secretions. If his care plan and speech therapy say he requires meal supervision, then yes he should be supervised. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 7 of 15 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 08/23/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm On 8/23/24, at 9:50 am, V1, Administrator, stated, We recognize the importance of residents on modified diets or at risk for choking and expect for them to be supervised in their room or come out to the assisted dining room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 8 of 15 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 08/23/2024 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 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. Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag and tubing were not touching the floor and the urinary bag was covered for one (R2) resident of two residents reviewed for urinary catheters in a sample of 33. Findings include: The facility's Catheter Care policy, revised 1/24/23, documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R2's current Physician Order Sheet/POS documents R2 has a urinary catheter. On 8/20/24, at 10:24 am, R2 is in bed with an uncovered indwelling urinary catheter bag draining yellow urine. R2's catheter bag and tubing are touching the floor. On 8/20/24, at 12:44 pm, R2 was in bed with an indwelling urinary catheter bag and tubing touching the floor. On 8/20/24, at12:50 pm, V8, Certified Nursing Assistant/CNA, verified R2's catheter bag and tubing are on floor and the bag is without a privacy bag. V8 stated, It should have a privacy bag and be tied up so it's not touching the floor. On 8/23/24, at 1:03 pm, V3, Director of Nursing/DON, confirmed indwelling urinary catheter bags should be covered and off the floor, as well as the tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 9 of 15 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 08/23/2024 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 Based on observation, interview, and record review, the facility failed to place an oxygen sign outside resident bedrooms for two residents (R8 and R14), have a physician order for the cares and administration of oxygen for one resident (R8), and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R18) of three residents reviewed for oxygen therapy in the sample of 33. Residents Affected - Few Findings Include: The Oxygen Policy, dated 5/10/21, documents, Oxygen is administered to residents who need it. Consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility's Oxygen Safety Policy. 1. R14's Physician Order, dated 3/12/24, documents oxygen at 2 (two) liters per minute by nasal cannula every shift. R14's Care Plan documents R14 has altered respiratory status/difficulty breathing related to Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. R14's oxygen setting is to be at 2 (two) liters per minute by nasal cannula. On 8/20/24 at 10:46 am, R14 was lying in bed wearing oxygen. There was no sign on R14's door to indicate oxygen was in use. On 8/21/24 at 2:45 pm, V3/Director of Nursing confirmed R14 did not have an oxygen sign located on his door or doorway. V3 also stated there should be an oxygen sign on all residents' rooms that have oxygen. 2. On 8/20/24 at 10:22 am, R8 was resting in bed with oxygen infusing via nasal cannula. There was no signage for oxygen on R8's bedroom door. On 8/21/24, at 2:34 pm, R8 was in bed with oxygen infusing via nasal cannula. There is no signage on the door for oxygen in use. R8's current Physician Order Sheet/POS does not include any oxygen orders for use or cares of oxygen supplies. R8's August 2024 Medication Administration Record/MAR does not include any documentation of oxygen supplies/cares of. On 8/21/24, at 2:35 pm, V10, Licensed Practical Nurse/LPN, verified there is no oxygen in use signage on R8's door and there should be. On 8/23/24, at 1:12 pm, V3, Director of Nursing/DON, confirmed a physician order must be obtained for the usage and cares of oxygen. 3. R18's current POS (Physician Order Sheet) documents a Physician order for Ipratropium-Albuterol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 10 of 15 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 08/23/2024 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 Solution 0.5mg (milligrams)/2.5mg/3 milliliters one vial inhalation orally four times a day. Level of Harm - Minimal harm or potential for actual harm On 8/21/24 at 11:34 am, R18's nebulizer tubing and nebulizer mask was lying on R18's nightstand, un-bagged and dated 8/13/24. V14/Licensed Practical Nurse confirmed R18's nebulizer tubing and mask were dated 8/13/24 and not bagged. V14 stated, Nebulizer tubing and mask should be changed at least once weekly (on Sunday evenings) and be bagged when not in use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 11 of 15 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 08/23/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide documentation of collaboration of care between the facility and the Dialysis center for one of one resident (R66) reviewed for Dialysis in a sample of 33. Residents Affected - Few Findings include: The facility's Dialysis policy, revised 2/14/24, documents, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders the comprehensive person-centered care plan, and the residents' goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. Policy Explanation and Compliance Guidelines: 4. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. 5. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report. R66's Treatment Administration Record/TAR, dated August 2024, documents R66 receives Dialysis. On 8/20/24, at 10:59 am, R66 sat in a wheelchair in his room. R66 stated he goes to dialysis on Monday, Wednesday, and Friday. R66's clinical record did not include any Dialysis Communication forms from 7/20/24 to current. On 8/22/24, at 3:15 pm, the facility provided two Dialysis Communication forms, dated 8/7/24 and 8/16/24. On 8/23/24, at 11:00 am, V1, Administrator, was unable to provide any further dialysis communication forms, and confirmed they should have them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 12 of 15 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 08/23/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 89 residents residing within the facility. Residents Affected - Many Findings include: The facilities CMS (Centers for Medicare and Medicaid services) Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 8/20/24 and signed by V1/Administrator, documents 89 residents currently reside within the facility. The facility's Nurse Schedule dated August 4 to August 31, 2024, documents the facility did not have the services of an RN at least eight hours a day on 8/4/24, 8/11/24, 8/17/24, and 8/18/24. On 8/23/24 at 12:00 pm, V1/Administrator verified they are required to have at least 8 hours of RN coverage daily, based on the staffing calculator the facility utilizes and the number of skilled residents. On 8/23/24 at 12:15 pm, V3/Director of Nursing stated, I am responsible for scheduling the nurses. V3 verified the nursing schedules were accurate and (the facility) did not have an RN for at least eight hours on 8/4/24, 8/11/24, 8/17/24, and 8/18/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 13 of 15 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 08/23/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper PPE (Personal Protective Equipment) was donned and handwashing was performed for one COVID-19 (Coronavirus Disease of 2019) positive resident (R58), and failed to ensure Enhanced Barrier Precautions signage was posted for one resident with an indwelling urinary catheter (R2) of 18 reviewed for infection control in a sample of 33. Residents Affected - Few Findings include: 1. The facility's COVID-19 Prevention, Response and Reporting policy, revised 5/31/24, documents, Policy Explanation and Compliance Guidelines: 16. HCP (Health Care Personnel) who enter the room of a resident with suspected or confirmed SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection should adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) - approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. On 8/20/24, at 12:41 pm, R58 was in a COVID-19 isolation room. V8, Certified Nursing Assistant/CNA, entered R58's room carrying a meal tray with a gown and surgical mask on. R58 was not wearing gloves or eye protection. R58 removed the gown and, without performing hand hygiene, continued to go in and out of other resident rooms passing meal trays. On 8/20/24, at 12:45 pm, V8 verified V8 should have put an N95 mask on before going into R58s' room. V8 stated, I didn't think I had to wear gloves unless doing cares. R58's current Physician Order Sheet/POS documents R58 has a diagnosis of COVID-19. On 8/22/24, at 11:56 am, V3, Director of Nursing/DON, stated to enter a COVID resident room, The staff should be wearing N95 face mask, eye protection, gown and gloves. V3 confirmed staff should perform hand hygiene upon exiting an isolation room and before further tasks or entering other resident rooms. 2. The facility's Infection Prevention and Control Program, revised 1/6/24, documents, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .Policy Explanation and Compliance Guidelines: Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. This policy also stated 12. Resident/Family/Visitor Education and Screening: c. Isolation signs are used to alert staff, family members, and visitors of transmission-based precautions. d. Passive screening, such as signs, are posted in the facility to alert family members and visitors to adhere to handwashing, respiratory etiquette, and other infection control principles to limit spread of infection from family members and visitors. On 8/20/24, at 12:44 pm, R2 was lying in bed with an indwelling urinary catheter draining urine. No Enhanced Barrier Precaution signage was posted on R2's door. Red isolation bins were in R2's room. The facility's Enhanced Barrier Precautions list of residents includes R2's name. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 If continuation sheet Page 14 of 15 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 08/23/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 8/21/24, at 2:35 pm, V10, Licensed Practical Nurse/LPN, confirmed R2's door does not include any signage for precautions and stated R2 should have one for Enhanced Barrier Precautions due to his catheter. On 8/22/24, at 12:01 pm, V3, Director of Nursing/DON, stated for residents on Enhanced Barrier Precautions, there should be a sign posted for Enhanced Barrier Precautions on their door and staff should wear gown, gloves, and mask when providing cares. Event ID: Facility ID: 145647 If continuation sheet Page 15 of 15