Inspection·May 24, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly notify the resident's physician of a change in condition for one of three residents reviewed for significant change in a sample of four. Findings include: The facility's Notification of Change Policy, dated 2/10/225, documents, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification included: Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status. R1's Face Sheet documents R1 admitted to the facility on [DATE] ,with the following diagnoses: Metabolic Encephalopathy, Cerebral Atherosclerosis, Type Two Diabetes Mellitus, Chronic Kidney Disease, and Alzheimer's Disease. R1's MDS (Minimum Data Set) Assessment, dated 4/11/25, documents R1 is severely cognitively impaired. R1's Progress Note, dated 4/3/25 and signed by V8/RN (Registered Nurse), documents, (R1) exhibited significant agitation and was highly resistant to care. (R1) was observed attempting to ambulate and transfer independently, demonstrating increased difficulty and decline in gait balance, compared to her baseline. Despite staff efforts to approach and assist, (R1) remained uncooperative and did not allow physical contact. Notably, (R1's) gait has deteriorated, placing her at an increased risk for falls. R1's Progress Note, dated 4/4/25 and signed by V8/RN, documents, (R1) continues to demonstrate a noticeable decline in gait and balance. Overnight, (R1) made multiple attempts to stand from her wheelchair but was unable to do so as (R1's) legs repeatedly gave out. (R1) is also exhibiting increased confusion and difficulty following simple instructions. While seated in her wheelchair, (R1) was observed sliding down and had to be boosted back up several times. While being transferred to bed, two staff members had to assist, which represents a notable decline from (R1's) baseline. (R1) did not bear weight during transfer, and her legs buckled during the stand-pivot maneuver. R1's Emergency Department to Hospital admission Note, dated 4/4/25, documents, Disposition: Admit. Clinical Impression- 1. Urinary Tract Infection. 2. Altered Mental Status. (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 2 Event ID: 145647 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 05/24/2025 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)