Health inspection·February 25, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to answer call lights in a timely manner for two of three residents (R1, R2) reviewed for call light wait times in the sample of five. Residents Affected - Few Findings Include: The facility's Call Lights: Accessibility and Timely Response policy dated 1/5/25 documents all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility Resident Council Meeting Minutes dated 1/27/25 document complaints of call lights taking 30 minutes or longer to be answered. Residents voiced that the staff often answer the call lights, turn the light off, say they will be back, but then never return to meet the resident's need. 1. R1's Medical Diagnoses List dated February 2025 documents R1 is diagnosed with Ischemic Heart Disease, Congestive Heart Failure, Type II Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Asthma, Chronic Kidney Disease, Major Depression, Hypertension, Anxiety, Pain, Insomnia, and Obesity. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and requires a wheelchair and is dependent on staff for transfers and Activities of Daily Living. R1's Care Plan dated 10/17/23 documents R1 is a high fall risk and requires her call light within reach and prompt response and assistance. On 2/6/25 at 2:30 PM R1 stated often it takes staff 25-30 minutes to answer a call light and then sometimes they will say they need to go get help and never come back. Sometimes she is left on the bedpan for quite a long time which is very uncomfortable. 2. R2's Medical Diagnoses List dated February 2025 documents R2 is diagnosed with Muscle Wasting, Paralytic Gait, Reduced Mobility, Anxiety, Major Depression, History of Falls, and Obesity. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact and requires a wheelchair and is dependent on staff for transfers and Activities of Daily Living. On 2/6/25 at 1:30 PM R2 stated on I put on my call light and very often the aides come in and turn off the call light, leave and then don't return to help me. Page 1 of 10 145965 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0558 Level of Harm - Minimal harm or potential for actual harm On 2/6/25 at 2:00 PM V2 Director of Nurses confirmed call lights need to be answered quickly. Staff need to assist residents right away or in the event staff need to leave the room, they need to come back within a reasonable time frame and meet the resident's need. Residents Affected - Few 145965 Page 2 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement resident centered interventions to prevent skin breakdown and worsening of pressure sores and failed to notify the wound physician and dietician of new open areas for one resident (R2) of three residents reviewed for pressure ulcers in a sample list of five residents. These failures resulted in R2 developing a stage four pressure area to R2's right ischium and unstageable pressure areas to R2's bilateral heels. Residents Affected - Few The Immediate Jeopardy began on 1/20/25 when the original open area was observed to R2's Right Gluteal Fold and the wound nurse practitioner was not notified. V1 Administrator was notified of the Immediate Jeopardy on 2/20/25 at 4:00PM. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 2/21/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and wound care audits. Findings Include: The facility's policy Pressure Injury Prevention and Management reviewed 2/6/24 states The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document findings in the medical record. The attending physician will be notified of the presence of a new pressure injury upon identification, the progression towards healing or lack of healing, of any pressure injuries weekly. Any complications (such as infection, development of a sinus tract etc.) as needed. The facility's policy Incontinence reviewed 12/19/24 states: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services to ensure resident is maintained at highest functioning level related to continence of bowel and bladder and to assist in maintaining that level. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Appropriate skin care will be maintained for those residents that are incontinent. On 2/19/25 at 3:35PM R2's Ischium/Coccyx wound measured approximately four inches in diameter and three inches deep with malodorous yellow drainage. Muscle and bone were visible. Both heels had leathery black eschar approximately 2.5 inches in diameter. R2's admission Progress Note dated 12/18/24 at 3:00PM documents Skin is intact; old bruising from fall that caused hospital admission. R2's Physician's Order Summary printed 2/6/25 includes the following diagnoses: Obesity, History of Cerebral Infarction, Muscle Weakness, Generalized Anxiety Disorder, Major Depression, Paralytic Gait, and Reduced Mobility. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact, wheelchair dependent, dependent for transfer and toileting, and requires substantial/maximal assistance of staff for rolling in bed. This MDS also documents R2 is frequently incontinent of urine and bowel. 145965 Page 3 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R2's standardized skin evaluation (Braden Scale) dated 12/30/24 at 1:15PM documents Braden Evaluation: Moisture: Occasionally moist. Activity: Chairfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Adequate. Friction and shear: Potential problem. R2's progress note dated 1/20/2025 at 2:58AM documents CNA stated that she had found an open area on right buttock while changing resident and performing care to get ready for bedtime. Writer cleansed area with wound cleanser and applied (Medical Grade) honey and covered with border gauze. There is no documentation a physician or family was notified. There is no wound assessment documented until 1/23/25. The facility's Wound Weekly Observation Tool dated 1/23/25 identifies this wound as number four. This wound assessment documents the wound measures 1.3 x 0.6 x 0.1 cm (centimeters). The section of the assessment concerning peri wound appearance is left blank on this assessment. The January Treatment Administration Record (TAR) for January 2025 documents a treatment order change dated 1/24/25. The treatment orders: Cleanse right gluteal fold with wound cleanser. Pat dry. Apply (Medical Grade) honey then hydrocolloid every three days. The next documented Wound weekly observation tool is dated 2/5/25. In this document the wound is renamed Right Ischium and measures 3.8 x 4.5 x 0 cm. This evaluation does not identify the wound as pressure wound and no stage is identified. R2's Wound Evaluation and Management Summary dated 2/5/25 by V8 Wound Nurse Practitioner documents a Stage IV pressure wound of greater than 10 days duration to R2's right ischium measuring 3.0 cm length by 3.6 cm width by 0.6 cm depth. This evaluation recommends a low air loss mattress. R2's Wound Evaluation and Management Summary dated 2/19/25 by V8 Nurse Practitioner documents the Stage IV Pressure Ulcer to R2's right ischium now measures 8.0 x 5.0 x 4.5 cm. R2's progress note dated 1/9/25 at 9:27PM documents (R2) has blood blisters to both heels. Left heel wound measurement 1.2 cm X 1.5 cm. Right heel wound measurements 1.2 cm x 1.0. On 1/9/25 a physician's order was initiated per R2's January Treatment Administration Record (TAR) to Cleanse wounds with Normal Saline pat dry. Applied betadine to wound. Abdominal pad and wrapped with (rolled gauze) to both feet. Wound nurse notified of heels. No treatment is documented on R2's Medication Administration Record (MAR) until 1/11/25. Treatment is ordered daily. R2's MAR does not document treatment as completed as ordered 1/13/25, 1/24/25, or 1/28/25. R2's Initial Wound Evaluation and Management Summary dated 1/22/25 by V8 Nurse Practitioner documents an unstageable deep tissue pressure injury of greater than 14 days duration measuring 0.9 cm length by 2.2 cm width on R2's right heel and an unstageable deep tissue pressure injury of greater than 13 days duration measuring 3.8 cm length by 4.4 cm width on R2's left heel. There is no documentation to address R2's open area on the right gluteal fold. This evaluation recommends pressure relieving boots. R2's Wound Evaluation and Management Summary dated 1/29/25 by V8 Nurse Practitioner documents an 145965 Page 4 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few unstageable deep tissue pressure injury of greater than 21 days duration on R2's right heel and an unstageable deep tissue pressure injury of greater than 20 days duration measuring 3.8 cm length by 4.5 cm width on R2's left heel. This evaluation recommends pressure relieving boots. R2's Wound Evaluation and Management Summary dated 2/5/25 by V8 Nurse Practitioner documents an unstageable deep tissue pressure injury of greater than 28 days duration measuring 2.8 cm length by 2.5 cm width on R2's right heel and an unstageable deep tissue pressure injury of greater than 27 days duration measuring 3.8 cm length by 4.5 cm width on R2's left heel. R2's Wound Evaluation and Management Summary dated 2/19/25 by V8 Nurse Practitioner documents the Stage IV Pressure Ulcer to R2's right ischium now measures 8.0 x 5.0 x 4.5 cm. On 2/6/25 at 10:50AM R2 was seated in the therapy room in a bariatric wheelchair. At 11:30AM R2 was at the lunch table eating in the wheelchair. At 1:30PM R2 was sitting in R2's room in the wheelchair. R2 stated I put on my call light and very often the aides come in and turn off the call light and then don't return to help me. I have bed sores and they don't change my (adult diaper). I (urinated) this morning in therapy and I have sat up in this chair since about 9:00AM without being changed. I'm afraid to complain because it might get worse. The wound doctor was pretty upset yesterday. I have these bed sores on my feet and the doctor has been seeing me for those, but I have one on my butt too and they didn't tell the doctor about that until yesterday. There were no pressure relieving boots in place during the above observations. R2 does not have a pressure relieving mattress in place to her bed. R2 stated the doctor said I should have a special mattress, but I haven't got one. On 2/6/25 at 2:00PM V2, Director of Nursing stated V2 is the person responsible for wound care. V2 verified the wound Nurse Practitioner has recommended a low air loss mattress for (R2), and that the mattress was ordered. V2 did not offer an explanation as to why the pressure relieving boots were not in place. V2 verified that R2 should be checked and changed at least every two hours and as needed or when requested and that staff should never turn off a call light and fail to return. The facility Resident Council Meeting Minutes dated 1/27/25 document complaints of call lights taking 30 minutes or longer to be answered. Residents voiced that the staff often answer the call lights, turn the light off, say they will be back, but then never return to meet the resident's need. On 2/6/25 at 3:39PM V8 wound care Nurse Practitioner verified it would have been V8's expectation that incontinence care should be completed every two hours and as needed and moisture is a contributing factor in (R2's) facility acquired pressure injuries and interferes with heeling. V8 stated (R2) is right I was very concerned the facility did not report the area on (R2's) ischium until it was a Stage IV (pressure sore). Pressure caused the skin breakdowns and moisture contributed to the worsening. V8 further stated I think the facility should provide training for the nurses and the DON in wound care. Also offloading (weight) off the wound is critical. V8 verified the pressure ulcers R2 is experiencing were avoidable. V8 also stated maybe that area on (R2's) ischium did start out as a moisture associated skin deterioration, but by the time I saw it was definitely a Stage IV pressure ulcer. R2's Wound Evaluation and Management Summary dated 2/12/25 documents Unstageable Pressure wound to right heel 2.8 x 2.6 cm, Unstageable Pressure wound to left heel 3.9 x 4.0 cm, Stage IV Pressure Ulcer to right Ischium 7.0 x 5.0 x 3.0 cm. On 2/19/25 at 9:30AM R2 was not wearing boots as recommended by Wound Nurse Practitioner. R2 stated 145965 Page 5 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0686 Level of Harm - Immediate jeopardy to resident health or safety the boots were in her drawer. R2, who is cognitively intact per most recent MDS, stated she had become incontinent of bowel while standing in therapy at around 4:00PM yesterday. R2 stated Therapy Staff brought R2 back to her room and put on the call light. R2 states a CNA came to R2's room and turned off the call light but did not clean R2. R2 stated R2 put the call light back on at 4:30 PM and the same CNA came in and turned off the call light and stated they were busy and would clean R2 up as soon as they could. R2 stated it was 7:00PM by the time R2 was cleaned up. Residents Affected - Few On 2/19/25 at 9:10AM V12 CNA stated she was familiar with the care needed for R2 as V12 takes care of (R2) most days. V12 stated V12 was not aware R2 needs to wear the boots. V12 also stated I believe what (R2) says is accurate. On 2/19/25 at 9:10AM V13, LPN verified R2 told V13 this morning (R2) was left without being cleaned yesterday from 3PM to 7PM, V13 stated I don't know why (R2) would say that if it didn't happen. On 2/19/25 at 12:30PM V18 Dietary Manager verified R2 had not been seen by the dietitian for (R2's) Pressure ulcers. On 2/19/25 at 12:40PM V14, Corporate RN verified that it is the facility's expectation that all residents with new skin concerns be evaluated immediately by the dietitian. On 2/19/25 at 3:35 PM V8, Wound Care NP stated if I had been aware of the wound on R2's Ischium sooner I could have made recommendations and evaluated and treated before the wound became so extensive. R2's ischium/Coccyx wound measured approximately four inches in diameter and three inches deep with malodorous yellow drainage muscle and bone were visible. Both heels had leathery black eschar approximately 2.5 inches in diameter. The Immediate Jeopardy that began on 1/20/25 was removed on 2/21/25 when the facility took the following actions to remove the immediacy. 1. On 2/19/25 R2's wounds were assessed and treated by wound care consultant staff. 2. On 2/20/25 R2 was educated on benefits of preventative measures and current treatment regimen. 3. On 2/19/25 a facility-wide skin audit was conducted by V2 DON/Designees with completion on 2/21/25. 4. On 2/20/25 facility-wide risk for skin breakdown assessments were initiated by V2DON/Designees with completion on 2/21/25. 5. On 2/21/25 an audit was conducted by V2 DON/RNC to ensure completion of risk for skin breakdown assessments and weekly/daily skin checks. 6. On 2/19/25 In-servicing was initiated by V2 DON/Designee for all Licensed Nurses on Pressure Injury Prevention and weekly skin checks. Completed on 2/19/25. V2 DON/Designee will be responsible for ensuring compliance of the program. 7. On 2/19/25 In-servicing was initiated by V2 DON/Designee of all Licensed Nurses and CNAs on incontinence care and call light response. Completed on 2/19/25. 145965 Page 6 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0686 Level of Harm - Immediate jeopardy to resident health or safety 8. V2 verified V2DON/designee will review four residents skin checks weekly for four weeks and then four residents skin checks bi-weekly for four weeks to ensure that all skin issues have been identified and properly treated. 9. V1 verified V1 Administrator/Designee will monitor call light response time four times a week for four weeks and then randomly thereafter. Residents Affected - Few 10. V2 verified V2 DON/Designee will in-service Licensed nursing staff and CNAs on call light response time, incontinence care, skin checks, and pressure injury prevention policy once a month for 3 months. 11. V2 verified V2 DON/Designee will be responsible for monitoring/tracking/processing of MD orders. 12. CNAs were in-serviced by DON/RNC/ADMINISTRATOR on reporting skin concerns to nurses with skin report sheet. Completed on 2/19/25. 13. The Facility is not utilizing agency staff at this time, but if the facility in the future utilizes agency staff DON/Designee will ensure in-serving on all processes prior to start date. 14. V2 verified V2 DON/Designee will be responsible for notification of Registered Dietitian and processing the recommendations. The facility presented an abatement plan to remove the immediacy on 2/21/25. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 2/24/25, and the survey team accepted the abatement plan on 2/24/25. 145965 Page 7 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

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 interview and record review the facility failed to provide safe transfers for two of three residents (R1, R2) reviewed for transfers in the sample of five. Findings Include: The facility's Safe Resident Handling/Transfers policy dated 12/15/24 documents all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Two staff members must be utilized when transferring residents with a mechanical lift. 1. R1's Medical Diagnoses List dated February 2025 documents R1 is diagnosed with Ischemic Heart Disease, Congestive Heart Failure, Type II Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Asthma, Chronic Kidney Disease, Major Depression, Hypertension, Anxiety, Pain, Insomnia, and Obesity. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and requires a wheelchair and is dependent on staff for transfers and Activities of Daily Living. On 2/6/25 at 2:30 PM R1 stated staff do not always use two people to transfer her with the full body mechanical lift. Sometimes the Certified Nurses Assistant (CNA) can not find anyone to help so they do it on their own. 2. R2's Medical Diagnoses List dated February 2025 documents R2 is diagnosed with Muscle Wasting, Paralytic Gait, Reduced Mobility, Anxiety, Major Depression, History of Falls, and Obesity. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact and requires a wheelchair and is dependent on staff for transfers and Activities of Daily Living. On 2/6/25 at 1:30 PM R2 stated on at least two recent occasions R2 has been transferred with the full body mechanical lift with the assistance of only one CNA. On 2/6/25 at 2:00 PM V2 Director of Nurses confirmed R1 and R2 require a full body mechanical lift for all transfers. V2 also confirmed all mechanical lift transfers require the assistance of two CNAs for the safety of both the residents and staff. 145965 Page 8 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours for six of fifty-five days reviewed for RN staffing. This failure has the potential to affect all 95 residents in the facility. Findings include: The facility Nursing Schedule (January 1, 2025 through February 24, 2025) documents on 1/3/25, 1/13/25, 1/17/25, 1/27/25, 1/31/25 and 2/11/25 the facility floor schedule assignment sheets did not document eight (8) hours of RN coverage for a 24 hour period. On 2/24/25 at 12:05pm, V1 Administrator confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have eight (8) hours of RN coverage in a 24 hour period on 1/3/25, 1/13/25, 1/17/25, 1/27/25, 1/31/25 and 2/11/25. The facility Resident Midnight Census dated 2/24/25 documents 95 residents reside in the facility. 145965 Page 9 of 10 145965 02/25/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review the facility failed to maintain an accurate facility assessment which is reviewed no less than annually and is updated as needed. This failure has the potential to affect all residents who reside in the facility. Findings Include: The facility census dated 2/6/25 documents 95 residents reside at the facility. The Facility Assessment does not document date or time the interdisciplinary team met to review the facility assessment or document it had been reviewed at least annually. The assessment does not address the direct care staff needed to meet the needs of the resident population by shift. On page ten of the assessment under the resident need Behavioral symptoms and cognitive performance the number recorded was zero. The facility's Matrix (CMS802) printed 2/6/25 at 9:40AM documents the facility has 29 residents diagnosed with Alzheimer's or Dementia. On 2/24/25 at 2:10PM V1, Administrator, verified the facility assessment was not accurate and provided a signature page with the date 12/20/24 separate from assessment. 145965 Page 10 of 10