Health inspection·November 26, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure resident rooms are clean and free of debris and the walls are in good repair. This failure affects five (R6, R7, R2, R8, R4) of eight residents reviewed for environment on the sample list of eight. Findings include: The facility's Resident Council Meeting minutes dated 9/9/24 document residents would like for housekeeping to clean their rooms better and take out their trash. The Resident Council Meeting minutes for 10/14/24 document residents would like housekeeping to clean their rooms and not complain when they are doing their jobs. The Resident Council Meeting minutes for 11/11/24 document residents would like housekeeping to clean their rooms better and not complain when they are doing their job. On 11/25/24 at 9:10 AM, R6's room contained piles of unfolded blankets and full black trash bags piled on top of each other in corner of the room. The room was cluttered with boxes of cereal, shoes, and other items along the wall. The bedside table was covered with books, soda cans, and other items. On 11/25/24 at 9:12 AM, beside R7's bed, blankets and clothes were piled up along the floor. Seven empty Styrofoam cups, two empty soda cans and a pile of empty candy wrappers mixed with candy were on the top of R7's bedside table. On 11/25/24 at 10:30 AM, cases of tea were under R2's bed. Food items, bags of chips, piles of full grocery bags, clothes, and laundry baskets were stacked between the bed and the wall. An Oxygen concentrator was sitting in the middle of these piles. The windowsill was packed with drinks, food, perfumes, lotions, and sprays. There was no clear pathway on the side of bed between the bed and the heater in the room. A large package of toilet paper was lying on the floor in the room. R2's care plan dated 9/21/24 documents R2 is at risk for falls and poor safety awareness. On 11/26/24 at 9:30 AM, the walls in R8's room were scuffed with black marks around the base of the walls and paint was chipping off the walls in the corners, the doorways, and the windowsills. On 11/25/24 at 10:00 AM, R4 stated the staff don't always do the best job at cleaning the way R4 feels his room needs cleaned. There was a plate covered with dried food on a bed on the other side of the room and there was a cup with curdled orange juice sitting on the windowsill. On 11/25/24 at 1:30 PM, V2 Director of Nursing stated she does not feel housekeeping is cleaning rooms like they are supposed to be cleaned and many rooms have clutter. (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 6 Event ID: 146003 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 146003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab of Rock Springs, The 2530 North Monroe Street 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)