Inspection·September 27, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disposition of the supply; and Provide feedback about performance and practices related to medication administration and medication errors. The facility's Abuse, Neglect, and Exploitation policy and procedure, revised 12/5/23, documents: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a residents' belongings or money without the resident's consent. The Face Sheet for R1 includes the following diagnoses: Quadriplegia C1-C4 complete, Chronic Obstructive Pyelonephritis, Stage 2 Pressure Ulcer of Sacral Region, Low Back Pain, and Traumatic Left Hip Fracture. The current Physician Orders for R1 documents a physician order for Oxycodone 5 mg; give one tablet by mouth every six hours as needed for severe pain was ordered on 6/27/24. The current Care Plan for R1 documents R1 receives opiate medications related to Quadriplegia, has potential for pain related to Neuropathic pain with history of left hip fracture and stage II coccyx pressure ulcer. On 9/26/24 at 12:00 pm, R1 was sitting in a wheelchair in the dining room being assisted with meal. At 1:20 pm, R1 was being mechanically lifted from her wheelchair into bed and cares were provided. At 3:00 pm, R1 was lying in bed on her right side. R1 stated she doesn't take pain medications very often, but has them if she needs them. R1 stated she has pain off and on, and at the first of August she needed the Oxycodone for abdominal pain, but was told she didn't have any. R1 stated she asked to go to the hospital to get checked out. The MAR (Medication Administration Record) for R1, dated 7/1/24 through 7/31/24, documents R1 received three tablets of Oxycodone 5 mg during the month of July 2024; One tablet on 7/19/24, 7/25/24, and 7/26/24. The MAR for R1, dated 8/1/24 through 8/31/24, documents R1 did not receive any Oxycodone until 8/8/24. On 9/27/24 at 9:20 am, V2, DON (Director of Nursing), stated V11, Licensed Practical Nurse/LPN, informed her there was no Oxycodone for R1 in the medication cart. V2, DON, stated she called the Pharmacy and was told the medication had been delivered on the morning of 7/30/24. V2 was unable to locate the Packing Slip, Disposition Form, or the Oxycodone. V2 reported this to V1, Administrator, and an investigation was started. V2, DON, stated if the disposition sheet and the medication were missing, no one would have been able to count it, or know it was gone. On 9/27/24 at 9:25 am, V1, Administrator, stated she was notified by V2, DON, that a card of Oxycodone for R1 had been delivered on 7/30/24, and the staff could not find it. V1 stated she immediately started an investigation and was able to determine the medication was missing. V1 stated the facility video cameras were watched, medication carts and medication rooms were checked, and the locked document shred container was drilled open and searched. V1 stated inside the shred container there were the two packing slips for R1's Oxycodone proving the order date, when it was delivered, and an empty card of Hydrocodone. V1, Administrator, stated Nurses surrounding the time frame were interviewed, pharmacy was notified, and documents received regarding when medication was given, who gave the medication, and who ordered the medication. The Pharmacy was able to tell us that the Oxycodone was ordered three times, but the facility was unable to identify who ordered the medication due to the signatures being unidentifiable and not matching any of the Nurses working at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 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 145647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/27/24 at 12:15 pm, V11, LPN, stated she worked Friday 7/26/24 and gave (R1) Oxycodone on that Friday and she still had some, like half a card left. V11, LPN, stated she did not work again until the next Thursday, 8/1/24, and R1 complained of pain, and there wasn't any Oxycodone to give her. That is crazy she didn't have any pain medication. V11, LPN, stated she reported to V2, DON, who was going to call the pharmacy. V11, LPN, stated on Friday, 8/2/24, she was called to the office and V1, Administrator, and V2, DON, began asking (V11 LPN) about R1's pain medication. V11, LPN, stated she told V1 and V2 that (R1) doesn't ask for pain meds very often and (R1) had some the last day (V11) worked and when (V11) came back (R1) didn't have any. A Medication Error Report, #285 dated 8/2/24, documents: (Don/Director of Nursing) notified of issues with pain medication, Oxycodone. Through the course of initial investigation, it was identified that there was a full card of Oxycodone that had been delivered on 7/30/24 that was not present in the narcotic drawer. Resident went to the ER (emergency room) for c/o (complaints of) pain and reported to the ER that there was no pain medication available at (the facility). Immediate Action Taken: Investigation in progress. Final Five Day to Follow to (State Agency) 8/2/24. Has a UTI (urinary tract infection) per (local hospital) ER. DON on site to verify medication discrepancy. The facility replaced the missing medication for the resident, 8/2/24. The Daily Assignment Sheet for the 400 hall, dated 7/29/24 documents V20, LPN, worked the third shift from 6:00 pm to 6:00 am on 7/30/24. V19, Former LPN, worked on the 400 hall on 7/30/24 from 6:00 am to 6:00 pm. The Narcotic Shift Count form for the 400 hall medication cart, dated 7/4/24 through 7/30/24, documents the 400 hall narcotic medications were not consistently counted, by two Nurses, at shift changes on: 7/5/24, 7/6/24, 7/9/24, and 7/10/24 through 7/30/24. The 400 hall narcotic medications were not counted at all on: 7/7/24, 7/11/24, 7/12/24, 7/16/24, 7/19/24, 7/20/24, 7/21/24, 7/25/24, 7/26/24, and 7/27/24. The facility was unable to provide a Disposition form for R1's Oxycodone. The Daily Assignment Sheets document V19, Former LPN, worked the following days on the 400 hall: 7/15/24, 7/17/24, 7/18/24, 7/23/24,7/24/24, 7/27/24, 7/29/24, 7/30/24, and 7/31/24. The pharmacy Packing Slip and Packing Slip Proof of Deliver forms, dated 7/1/24, documents 30 tablets of Oxycodone 5 mg were ordered and delivered for R1. The facility provided a Phone Reorder Form, dated 7/18/24 at 5:01 pm, documenting V19, Former LPN, attempted to reorder Oxycodone 5 mg for R1, which was not sent by the Pharmacy due to being too early and was previously delivered on 7/1/24. The facility provided two Medication Re-order Forms documenting that Oxycodone 5 mg was again re-ordered for R1 two times on 7/29/24 via fax (facsimile) machine, with unidentifiable signatures consisting of one straight line and one scribbled marking. The Daily Assignment Sheet, dated 7/29/24, documents V19, Former LPN, worked from 6:00 am to 6:00 pm. The pharmacy Packing Slip, dated 7/29/24, documents Oxycodone was ordered for R1 and the Packing Slip Proof of Delivery, dated 7/30/24, documents a card containing 30 Oxycodone 5 mg were delivered and signed for by V20, LPN, the third shift Nurse at 5:23 am. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 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 145647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm The facility's initial report to the State Agency, dated 8/2/24, documents the facility verified misappropriation of R1's narcotic Oxycodone on 8/2/24. DON notified of issues with pain medication, Oxycodone. The facility replaced the missing medication for the resident on 8/1/24. Through the course of the initial investigation, it was identified that there was a full card of Oxycodone that had been delivered on 7/30/24 that was not present in the narcotic drawer. The local Police were notified, and case (number) filed. Final to follow. Residents Affected - Few The Facility investigation documents interviews were obtained on 8/2/24 from the Residents from the 400 hall and with V11, LPN/Licensed Practical Nurse, V19, Former LPN, V20, LPN, and V21, LPN. V11, LPN's, interview documents V11, LPN, dispensed one Oxycodone to R1 on 7/26/24 and recalls there being approximately a half of card (15) of Oxycodone remaining, and when she returned to work on 8/1/24 there was no Oxycodone available for R1. V19, Former LPN's, interview documents numerous attempts were made to contact V19 without success, and when V19 arrived at the facility for her 6:00 pm shift (V19) was immediately escorted to the conference room and advised she was being suspended for not following facility policy for narcotic count; reasonable suspicion of missing narcotics-Oxycodone. V19, Former LPN, denied knowing of anyone taking R1's medications from the facility. V19, Former LPN, stated, You all want to do a drug test, do it: when they low I re-order; resident (R1) asked for a pain med, look at the sheet; I be on my meds as (V2, DON) be on me to reorder; may have been a few on the card prompted me to reorder; don't remember calling in a refill; sometimes I count cards sometimes I don't; maybe I did fax. V20, LPN's, interview documents V21 stated she put away the narcotics when they came from pharmacy the morning of 7/30/24, did not leave anything unattended on the medication cart. V20, LPN, stated when she handed off the keys on 7/30/24 to V19, Former LPN, there were two cards of Norco (Hydrocodone) in the medication cart and no Oxycodone. V20, LPN, stated right after shift change, V19, Former LPN, left the facility to go get gas and left report on the medication cart. V21, LPN, denied seeing narcotics being taken out of the facility. This Report documents video surveillance verified: V20, LPN, placed narcotic medications into the 400 hall narcotic medication lock box on 7/30/24 prior to shift change; V19, Former LPN, with bizarre behaviors of shuffling through papers in a bin at the Nurses Station; V19 putting something under her jacket, between her lab coat and jacket; V19 going into the medication room at 5:18 am and coming out of medication room at 5:18 am, then going back into the medication room at 5:19 am and coming back out at 5:21 am, without taking anything in or out of the room; and V19, Former LPN, leaving the facility . The facility's investigation summary documents: The facility notified the provider of the issue and orders received to replace the missing medication/Oxycodone for (R1) on 8/1/24. (The facility) pharmacy notified and the facility assumed the charges for the missing medication so (R1) not responsible for the cost of replacement. (Local City) Police notified of incident report #24-16252. Nursing staff assigned to the cart interviewed. Schedule and delivery times verified, and nurse assigned during the time frame in question immediately suspended. Reeducation of narcotic policy /process started with licensed nursing staff. VP (Vice President) of Clinical Services assisted with the investigation. Recycle bins emptied; cart thoroughly checked and reconciled. R1 interviewed and denied current pain and stated she has received her pain meds when requested. Thirty resident interview and all state their medication needs have been met; they are receiving their pain meds to address pain, and all feel safe at the facility. The facility's Disposition documents: Through the course of the investigation the facility has substantiated missing medication/Oxycodone. The facility replaced the medication at no charge to the resident. The (City) Police Department notified and formal report made #24-16252; The officer stated there was not enough evidence to charge the suspended nurse member criminally. The suspended nurse was not reinstated; terminated for not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145647 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 145647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete following process and reasonable suspicion based on observations through the course of the investigation. The facility used this incident as an opportunity to improve its processes and provide additional reeducation on medication management/inventory control. The employee file for V19, Former LPN, includes a Disciplinary Action Form that was completed for V19, Former LPN, on 8/9/24. This form documents V19, Former LPN, was terminated on 8/9/24 for reasonable suspicion and not following facility policy and procedure for missing medications, medication administration, and narcotic counts. Event ID: Facility ID: 145647 If continuation sheet Page 5 of 5