Health inspection·January 7, 2025

F 0921 Level of Harm - Potential for minimal harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to ensure utility rooms and nurses stations were clean, in good repair, and free of debris. This failure has the potential to affect all 105 residents residing in the facility. Findings include: On 1/7/25 at 12:30 PM V8, Housekeeping supervisor, stated that housekeeping staff are to clean, sweep and mop the nurses station and clean clean/soiled utility rooms daily. On 1/7/25 at 1:15 PM V8 opened the door to the 3rd floor soiled utility room. The sink and cabinet were falling away from the wall and collapsing in the front. Upon closer inspection, opening the cabinet doors under the sink the floor of the cabinet was covered in a black substance and pulling away from the cabinet. V8 turned on the water at the sink, the water immediately drained into the under sink compartment not down the drain. V8 stated V8 filled out a maintenance request form two weeks ago. On 1/7/25 at 1:18 PM V9 Maintenance Director came to the 3rd floor soiled utility room. V9 confirmed the sink and cabinet are pulling away from the wall, that the sink leaks water under the cabinet, there is a black substance under the sink on the cabinet floor, and the toe kick board is wet and collapsed under the front of the cabinet and covered with the same black substance as inside the cabinet. V9 confirmed knowing the sink/cabinet needed repaired and a maintenance request had been reported. On 1/7/25 at 1:20 PM V8 opened the door to the 3rd floor clean utility room. V8 confirmed the floor had dirt and debris on it and had not been cleaned in a substantial amount of time. On 1/7/25 at 1:23 PM V8 opened the door to the 4th floor soiled utility room. V8 confirmed the sink caulking securing the sink to the counter was in disrepair, missing in some parts and had a black substance on it. V8 confirmed the back splash was in disrepair and coming apart. V8 confirmed the floor under the sink was discolored, contained dirt and debris, and that tile was in disrepair around the edges and had not been cleaned in a substantial amount of time. On 1/7/25 at 1:25 PM V8 opened the door to the 4th floor clean utility room. V8 confirmed the floor had dirt and debris on it and had not been cleaned in a substantial amount of time. On 1/7/25 at 1:28 PM V8 confirmed the baseboards and toe kick boards around the fourth floor nurses station contain dirt and debris and looked like it had not been cleaned in a substantial amount of (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: 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 01/07/2025 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)