Health inspection·July 22, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to maintain clean comfortable rooms consisting of clean floors and rooms that are free of dirty dishes and debris for two (R1, R2) of three residents reviewed for comfortable homelike environment.Findings Include:On 7/21/25 at 10:00 AM initial tour of the facility hallways labeled 100, 200 and 300 observed to have several unmade beds, some beds observed without linen, some beds had soiled linen on the unmade bed. 1. R1's Minimum Data Set, dated on July 11, 2025, documents R1 as cognitively intact.On 7/21/25 at 1:15 PM R1 stated the staff does not make the bed daily, and often times there are dishes left over in his room from meals that he doesn't eat in the dining room. R1 stated that R1 prefers bed/sponge baths and staff do not change the sheets on the bed after wiping him down. On 7/21/25 at 11:10 AM V3, R1 family, stated V3 visited R1 recently during lunch time, there was trash on the floor, used gloves on the floor, and used napkins on the floor. V3 stated that there were dirty dishes with old food on them and flies in the room, as well as dirty linen on the unmade staff for activities of daily living. On 7/21/25 at 10:22 AM R2's room contained two meal cover lids, inside of the lids was 4 used glasses containing thickened liquids. Two of the glasses were still full of liquid and two glasses were 3/4 full of thickened liquid. The bedside table in front of R2 contained two full Styrofoam cups both with lids in place containing thickened liquids. R2's bed was unmade; the bottom sheet was not spread out evenly and the top sheet was touching the floor on the right side of the bed. On 7/21/25 at 12:00 PM V4 License Practical Nurse confirmed R2 is lying in an unmade bed and the bed is to be made by the nursing staff in the morning before breakfast time. V4 confirmed that the top sheet should not be touching the floor. V4 confirmed the dirty dishes are still in the room from previous meals and should be removed by the staff when R2 has completed his meal. On 7/21/25 at 12:50 PM V5 Regional Nurse confirmed nursing staff are to be making the residents bed after getting the resident out of bed and ready for the day. V5 confirmed staff should be removing used dishes from the room after the resident is done using them and returned to the kitchen. On 7/22/25 at 11:30 AM V2 Director of Nursing confirmed that nursing staff are to be changing and making the beds of the resident after getting the residents up for the day and completing morning cares. V2 confirmed that after residents consume meals in their room staff should be removing dishes. Resident Council Meeting Minutes dated 4/17/25 document resident complaints concerning housekeeping is not cleaning the floors properly in the building. Residents voiced they are not getting clean linen on the bed after showers.Resident Council Meeting Minutes dated 5/9/25 document resident complaints concerning housekeeping staff are not sweeping the floor, they are mopping up the trash and food with the mop. Residents voiced the bedside tables are not being cleaned. Resident Council Meeting Minutes dated 6/19/25 document resident complaints of certified nurses' Page 1 of 3 145965 145965 07/22/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0584 aides are not making the beds. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145965 Page 2 of 3 145965 07/22/2025 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

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 properly secure R2's indwelling catheter tubing, document urinary output every shift, and provide a dignity cover to cover the urinary collection bag. R2 is one of one residents reviewed for urinary catheters.Findings Include:On 7/21/25 at 10:22 AM R2 is observed lying in bed with indwelling urinary catheter tubing dangling from the bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway. On 7/21/25 at 12:00 PM V4 confirmed R2 is lying in bed with indwelling urinary catheter tubing dangling from the right bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway.On 7/21/25 at 2:20 PM V1, V2 and V5 confirmed R2 is lying in bed with indwelling urinary catheter tubing dangling from the right bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway. On 7/22/25 at 11:30 AM V2 confirmed R2's medical record contained a physician's order for the placement of an indwelling urinary catheter with a drainage bag, a physician order to monitor urinary output every shift and to use a drainage tubing securement device to be changed weekly. V2 confirmed R2's medical record contained multiple days that urinary output was documented every shift. V2 reconfirmed the urinary drainage bag was not enclosed in dignity bag. V2 confirmed the facility policy is to record urinary output every shift, place the drainage bag in a dignity bag and ensure call light is within reach.On 7/21/25 at 10:00 AM record review documents on 4/30/25 at 09:24 AM a physician's order was entered: Maintain indwelling catheter with 16 F 10 cc balloon for _____ (diagnosis) and change prn for obstruction. On 7/21/25 at 10:00 AM record review documents on 4/30/25 at 09:24 AM a physician's order was entered: Change catheter securement device every week.On 7/21/25 at 10:00 AM record review documents on 5/7/25 at 05:05 AM a physician's order was entered: Ensure catheter output was obtained and documented every shift and as needed. R2's Bowel and Bladder Output tracker for the date range of 7/9/25 - 7/21/25 was reviewed. The urine outputs were recorded on 7/9 (5:33 AM and 9:33 PM), 7/10 (9:21 PM), 7/11 (5:35 AM and 11:32 AM), 7/12 (None recorded), 7/13 (3:36 AM), 7/14 (1:52 PM), 7/15 (4:34 AM and 8:34 PM), 7/16 (5:39 AM and 9:45 PM), 7/17 (9:59 PM), 7/18 (5:11 AM and 8:27 PM), 7/19 (5:59 AM. 8:42 AM, and 8:51 PM) 7/20 (5:35 AM), and 7/21 (5:59 AM and 7:44 PM). The record showed that 7/19/25 is the only date in which there is a urine output recorded for all three shifts. On 7/22/25 at 11:00 AM Catheter Care Policy record review Date Reviewed/Revised: 2/10/2025 documents under section Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 6. Legs bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight. 21. Ensure call light is within reach. 24. Document and record output. Ensure to include amount, color, and clarity. 145965 Page 3 of 3