Health inspection·October 9, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two residents were properly secured in wheelchairs before transporting them in a van for two of three residents (R2, R5) reviewed for accidents in the sample list of five. This failure resulted in R2 falling from the wheelchair when the van suddenly stopped and suffering fractures to the humerus, fibula, and tibia with resulting pain and immobility.Findings include:R2's Current diagnoses list includes the following diagnoses: Chronic Kidney Disease Stage 5, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, Atrial Fibrillation with Anticoagulant, Type II Diabetes with Neuropathy, Heart Disease, Anxiety, and Depression.R2's Care Plan updated 8/17/25 documents (R2) uses a wheelchair for locomotion and requires a full body lift for transfer. This care plan also documents R2 is at risk for falls.R2's final report of incident documents On 9/16/25 (R2) was being transported to an appointment. During the transport the driver abruptly applied the brakes. (R2) fell forward on to the wheelchair foot rests. (R2) suffered fractures of the left humerus, left tibia and left fibula. Investigation determined the seatbelt did not properly lock in place.On 10/9/25 at 10:00AM V7, Human Resources Director stated (V9) Transportation Aide was terminated because (V9) was driving the facility van and hit the car in front of her. When (V9) hit the car (R2 and R5) were in the van going to a doctor's appointment. (R5) was shook up but not hurt. I think (R2) broke her leg and her shoulder. (V9) got a ticket. A copy of the citation (V9) was given for Failure to use due care was provided by V7.On 10/9/25 at 10:06AM V9 stated I was driving the facility van to (the hospital) for doctor's appointments with (R2, and R5). (R2) was seated behind me and (R5) was behind (R2). A car in front of me slammed on the brakes and I slammed on my brakes and slid into the other car. (R2) was not secured in the seat because the shoulder belt was broken and would not tighten. I told the last two Administrators, but nothing was done. I couldn't even use the other front wheelchair seat because the lap belt was missing. (R2) slid out of her wheelchair and on to the floor and hit the foot pedals. She was crying in pain. (R5) slid forward but not out of the wheelchair and she was anxious but ok. I immediately called 911 and the police and ambulance were there after a few minutes. They helped me get (R5) back in her chair and they ambulance crew took (R2) to the hospital.R2's Xray report of Left Tibia and Fibula dated 9/16/25 at 2:21PM states Oblique fractures involve the proximal meta diaphysis of the tibia with slight posterior and lateral angulation of the distal fragment. Oblique fracture involves the proximal diaphysis of the fibula. Fractures also involve the distal tibial metaphysis with the margins ill-defined. Fracture undermines the medial malleolus. R2's Xray report of Left shoulder dated 9/16/25 at 2:21 PM states Mildly displaced angulated fracture of the proximal humerus, centered at the surgical neck.On 10/9/25 at 9:30AM V12, Maintenance Director accompanied the surveyor to the transport van. V12 stated the van is currently not in service because several pieces have been ordered from the mobility company that services the harnesses because they were broken. The wheelchair securement system in the van was observed to be disassembled in several areas. V12 stated he does not know why the mobility company was called as he has just been in his position the past few days.On 10/9/25 at 9:45AM V13, former Maintenance Director stated After the van driver got fired, I went to pick up a resident from dialysis. I noticed the right front seatbelt was completely gone and the left front belts were broke and couldn't be tightened. I called (the mobility company) and they sent someone out. I think now we are waiting on parts. I did walk throughs in the van with the transporter, but I really didn't know how those harnesses worked.On 10/9/25 at 9:50AM V11, a technician from the company that builds and services wheelchair securement systems, stated On 10/7/25 according to my notes I went to (the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145965 If continuation sheet Page 2 of 3 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 145965 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility) to inspect and repair a wheelchair securement system. What I found in the front row of seating was that both shoulder belts were malfunctioning. One would not pull out and the other would not retract. One of the two seat belts was completely missing. Employees securing residents should have known it wasn't in safe working order. The occupant securement system was not fully functioning and that van should not have been in service. We recommend the securement system be inspected every six months. The last inspection we did was dated May of 2024.R5's Minimum Data Set MDS dated [DATE] documents R5 is cognitively in tact. On 10/9/25 at 2:00PM R5 was seated in her room in a wheelchair. R5 was agreeable to be interviewed. R5 stated Boy do I ever remember that wreck. The first I knew (V9) screamed out and I went flying forward. I didn't get tossed out of my chair because I got trapped between my wheelchair and the back of (R2's) wheelchair. (R2) went flying right out of her wheelchair and she hollered 'OUCH Help me Help me.' Then the cops (police) and ambulance guys came. I wasn't hurt, but I was lucky and I was sure shook up. (R2) was hurt and I haven't seen her back. That kind of worries me. (R2's) seat belts were real loose and I didn't have the lap belt or the shoulder belt on. I guess it could have been worse, but I was scared. On 10/9/25 at 2:30 V14, Nurse Practitioner verified the 9/16/25 accident caused the fractures of (R2's) humerus, fibula, and tibia. Event ID: Facility ID: 145965 If continuation sheet Page 3 of 3