Inspection·July 1, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to assess, monitor, and apply a physician ordered hand protector for contracture prevention, and ensure Range of Motion Services were provided for one (R39) of three residents reviewed for splints and contractures in the sample list of 53. Findings include: The facility's ADLs (Activities of Daily Living) Policy, dated 2/10/25, documents, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Policy Explanation and Compliance Guidelines: 2. The facility will provide a maintenance and restorative program if indicated to assist the resident in achieving and maintaining the highest practical outcome based on the comprehensive assessment. The facility's Facility Assessment, dated 9/5/2024, documents, Services and Care We Offer Based on Our Resident's Needs: General Care- Mobility and fall/fall with injury prevention. Specific Care or Practices: Transfers, Ambulation, Restorative Nursing, Contracture Prevention/Care. R39's Physician Order Sheet, dated 7/27/23, documents a Physician Order for a right-hand protector to prevent contracture twice a day. This order did not include parameters for how long splint should be on and when to remove the splint. R39's current Medical Diagnosis list documents Cerebral Infarction affecting right dominant side, Contracture of Right Hand, and Abnormalities of Gait and Mobility. R39's MDS (Minimum Data Set) Assessment, dated 5/17/2025, documents R39 is cognitively impaired, requires assistance with all ADLs, has an impairment on one side of R39's upper extremities, and an impairment on both sides of R39's lower extremities. R39's current Care Plan documents, (R39) has an ADL self-care performance deficit related to Activity Intolerance, Fatigue, Impaired balance, right hand contracture, memory loss, post laminectomy syndrome with pain, obesity. This same care plan does not document any active or passive range of motion exercises to R39's right hand. R39's electronic medical record does not contain any evidence of Range of Motion exercises being performed to R39's right hand. (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 07/01/2025 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)