Health inspection·March 26, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide notifications of discharge for two (R20 & R101) of two residents reviewed for discharge from a total sample list of 35 residents. Findings include: 1.) R20's undated census report documents discharges to the hospital on 8/14/25, 10/15/25, and 2/6/25. R20's medical record does not contain a bed hold or documentation of a transfer notification. 2.) R101's undated census report documents discharge to the hospital on [DATE]. R101's medical record does not include a bed hold, nor documentation of a transfer notification. On 3/25/24 at 9:00 AM, V1 Administrator stated that the facility did not notify the Ombudsman of discharge for R20, nor R101 on the above hospitalization dates. On 3/26/25 at 12:00PM, V30 Social Services Director stated that she is responsible for notifying the Ombudsman of resident discharges but was unaware that the notification included hospitalizations. I will start doing that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 2 of 20 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 03/26/2025 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)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide bed hold notices for two (R20 & R101) of two residents reviewed for transfers from a total sample list of 35 residents. Findings include: 1.) R20's undated census report documents discharges to the hospital on 8/14/25, 10/15/25, and 2/6/25. R20's medical record does not contain a bed hold notice or documentation of a refusal. 2.) R101's undated census report documents discharge to the hospital on [DATE]. R101's medical record does not include a bed hold, nor documentation of a refusal. On 3/25/24 at 9:00AM, V1 Administrator stated that the facility did not provide bed holds (notices) for R20, nor R101 on the above hospitalization dates. On 3/26/25 11:45AM V30 Social Services Director stated that the process for the facility is that the nurses on the floor are supposed to fill out the bed hold when a resident is discharged and then they get collected and scanned in. Our process isn't working. I know that we didn't get them for R20 nor R101 and we should have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 3 of 20 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 03/26/2025 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 complete a Pre-admission Screening and Resident Review (PASARR) level I for one (R45) resident out of one resident reviewed for PASARR level I in a sample list of 35 residents. Residents Affected - Few Findings include: R45's undated Face Sheet documents R45 admitted to the facility on [DATE]. This same face sheet documents medical diagnoses of Major Depressive Disorder, Anxiety and Schizoaffective Disorder which all have an initial date of 7/5/2021. R45's Minimum Data Set (MDS) dated [DATE] documents R45 as moderately cognitively intact. R45's Electronic Medical Record (EMR) does not document a PASARR level I completed. On 3/24/25 at 2:30 PM V1 Administrator stated the facility is unable to provide the Pre-admission Screening and Resident Review (PASARR) level I for R45. V1 stated, We (facility) looked for it and cannot find it. V1 Administrator stated the facility is obtaining a PASARR level I now. V1 Administrator stated the facility does not have a policy for PASARR's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 4 of 20 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 03/26/2025 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R6's undated Face Sheet documents medical diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetic Mellitus, Chronic Multifocal Osteomyelitis, Sacral Pressure Ulcer Stage 4, Anemia, Neuromuscular Dysfunction of Bladder, Urinary Incontinence and Hypokalemia. Residents Affected - Few R6's Physician Order Sheet (POS) dated March 2025 documents a physician order to cleanse R6's Sacrum with wound cleanser, apply moistened (antibacterial foam) and cover with foam three times per week and as needed. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. This same MDS documents R6 as being dependent on staff for eating, toileting, bathing, dressing, personal hygiene and transfers. R6's Pressure Ulcer Risk assessment dated [DATE] documents R6 as being at risk for pressure ulcers. On 3/25/25 at 11:30 AM V6 Licensed Practical Nurse (LPN) completed R6's Sacral Stage 4 Pressure Ulcer dressing change. R6 did not have a dressing in place over her Stage 4 Pressure Ulcer on her Sacrum. R6's quarter sized Sacral Pressure Ulcer had a very dark red center with white edges and minimal yellow drainage. R6's Sacral wound was in direct contact with her incontinence brief overly saturated with urine. R6's bedside table was cleared of items but had several dry liquid spills and unknown pieces of debris. V6 LPN placed R6's wound supplies directly on R6's contaminated bedside table. V6 LPN used the contaminated wound supplies to place directly on R6's open Stage 4 Pressure Ulcer. V6 LPN did not disinfect her scissors prior to cutting R6's Hydrofera Blue to the size of her wound. On 3/25/25 at 11:50 AM V22 Certified Nurse Aide (CNA) stated R6's Sacral dressing fell off during R6's shower at 8:00 AM that morning (3/25/25) and V22 let V6 LPN know that R6 needed a new dressing. On 3/25/25 at 12:00 PM V6 Licensed Practical Nurse (LPN) stated she should have disinfected her scissors prior to cutting R6's wound dressing. V6 LPN stated she contaminated R6's wound supplies by not providing a clean field prior to completing wound care for R6. On 3/25/25 at 1:15 PM V8 Licensed Practical Nurse (LPN)/Wound Nurse stated R6 should always have a clean covering over her Stage 4 Sacral Pressure Ulcer. V8 LPN/Wound Nurse stated the staff should always have a clean field to work off of to help prevent cross contamination. V8 LPN/Wound Nurse stated R6's wound could get infected if it is not covered and protected. V8 LPN stated V6 LPN should have applied another dressing directly after R6 was given a shower and the dressing was found to come off during the shower. The facility policy titled Clean Dressing Change dated implemented 8/05/2019 documents the staff should set up a clean field on the overbed table with needed supplies for wound cleansing and dressing application if the table is soiled, wipe clean, place a disposable cloth or linen saver on the overbed table. Based on observation, interview, and record review the facility failed to prevent two stage two pressure ulcers from developing, failed to prevent cross contamination during pressure ulcer care, and failed to implement dietary interventions for wound healing timely for three (R41, R6, & R352) of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 5 of 20 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 03/26/2025 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)

F 0686 seven residents reviewed for pressure ulcers from a total sample list of 35 residents. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few The facility policy dated 2/10/25 documents the facility will establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions and modifying the interventions as appropriate. 1.) R41's undated diagnosis sheet documents diagnoses including: Morbid Obesity. R41's Minimum Data Set, dated [DATE] documents R41 as cognitively intact. R41's admission skin assessment dated [DATE] documents no skin issues in the inguinal areas. R41's skin assessment dated [DATE] documents a skin issue on the left side of the inguinal area with no mention of the right side. On 3/24/25 at 3:28PM, V13 Certified Nursing Assistant and V14 Licensed Practical Nurse provided R41 perineal care and a stage two wound approximately four inches in length was observed on both the left and right sides of the groin. On 3/23/25 at 8:36AM, R41 stated she has sores on the inside of her legs because her briefs are too tight and have caused sores. R41 stated this has been going on for several weeks. On 3/24/25 at 3:30PM, V14 LPN stated the briefs that R41 is wearing are too small. You can see where they are cutting into her skin. V13 CNA stated, Those are the largest briefs we have. On 3/24/25 at 3:31PM, R41 stated the briefs hurt her skin and when they wipe her the open areas of the groin sting. On 3/25/25 at 11:00AM, V2 Director of Nursing stated she is ordering larger bariatric briefs for R41. 2.) R352's Physician Wound Notes dated 2/5/25 document R352 has an Unstageable Deep Tissue Injury (DTI) to the left buttock with undetermined thickness and an Unstageable DTI to the left heel with undetermined thickness. The DTI on the left buttock measured 3.5 centimeters (cm) by 3 cm and the DTI to the left heel measured 6 cm by 4.4 cm. On 3/25/25 at 01:54 PM, V26 Nurse Practitioner (NP)/Wound Care stated that she saw R352 for the first time on 2/5/25 and recommended the following: Vitamin C 500 milligrams (mg); Zinc Sulphate 220 mg once daily by mouth for fourteen days; Multivitamin once daily by mouth; and consultation with dietician regarding protein. R352's Medication Administration Record (MAR) dated 2/1/25 through 2/28/25 documents R352 did not received the multivitamin until 2/12/25, the Zinc until 2/12/25, and the Vitamin C until 2/11/2025. R352's medical record documents R352 was not seen by the dietician until 3/7/2025. This dietary note recommended that R352 have liquid protein 30 milliliters two times per day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 6 of 20 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 03/26/2025 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/25/25 at 3:32 PM, V20 Registered Nurse/Regional Clinical Consultant stated staff should be entering and implementing orders as soon as possible after receiving the providers notes and orders. On 3/26/25 at 8:12 AM, V2 Director of Nursing (DON) stated that when orders are received the expectation is for orders to be implemented within one or two days. V2 stated it was unusual for an order to go longer than two days without it being initiated. Event ID: Facility ID: 146003 If continuation sheet Page 7 of 20 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 03/26/2025 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)

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** 2. R40's undated Face Sheet documents Cerebral Infarction, Tracheostomy status, Metabolic Encephalopathy, Altered Mental Status, Abnormal Posture, Unsteady on Feet, Reduced Mobility, Muscle Weakness, Intellectual Disabilities and presence of Gastrostomy Tube (G-Tube). R40's Minimum Data Set (MDS) dated [DATE] documents R40 is moderately cognitively impaired. This same MDS documents R40 is dependent on staff for toileting, dressing, personal hygiene, bathing and bed mobility. R40's Fall Risk Evaluation dated 2/22/25 documents R40 as a fall risk. R40's Nurse Progress Note dated 1/22/25 at 9:00 PM documents R40 was found lying on his stomach on the floor beside his bed. R40 was assisted back to bed per staff. R40's Fall Investigation dated 1/23/25 documents R40 stated he slid out of bed. This same investigation documents, It appears (R40) did not realize (R40) was too close to the edge of the bed. On 3/25/25 at 2:15 PM V2 Director of Nurses stated R40 was positioned too close to the edge of his bed. V2 DON stated R40 was using a low air loss mattress at the time of his fall on 1/22/25. V2 DON stated the staff positioned R40 too close to the edge of his bed which caused him to roll out of bed. V2 DON stated R40 did have complaints of pain to his Right Wrist and an X-Ray was completed with negative findings. Based on interview and record review the facility failed to ensure a resident's personal electric fan was assessed for safety before use and failed to ensure a resident was safely positioned in bed to prevent a fall for two of two residents reviewed for accidents in the sample list of 35. Findings include: 1. The facility Electrical Safety Policy dated 2/11/25 documents that the intent of the policy is to provide staff with information about the facility's method for ensuring safety as it relates to electrical wiring and equipment. The Maintenance Director or designee is responsible for the inspection and testing of electrical components. This includes receptacles, power strips, extension cords, and equipment. A resident's personal electronic equipment shall be visually inspected prior to use. Nursing personnel are responsible for reporting new equipment to the Maintenance Director. R20's undated diagnosis sheet documents the following diagnoses: Quadriplegia, Urinary Tract Infections, Type II Diabetes Mellitus, Acquired Absence of the Left Upper Limb, Schizophrenia, Depression, Anxiety, Antibiotic Resistance and Multi-Drug Resistant Organisms. R20's progress notes dated 8/7/24 document that at 1:11AM the facility notified management of a fire in R20's resident room. R20's care plan dated 10/21/21 documents R20 is dependent on staff for all cares. The facility investigation dated 8/7/24 documents V24 Certified Nursing Assistant (CNA) heard R20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 8 of 20 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 03/26/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yell fire and when she entered R20's room saw R20's fan on fire on R20's bed. R20 was pulled away from the flame and the fire was extinguished. On 3/25/25 at 9:00 AM, R20 stated that the fan was his and was next to his head in the bed where he liked it. He woke up to smoke and yelled fire. R20 stated that his fan was old, and he could not recall anyone ever inspecting it. On 3/25/25 at 1:31 PM, V24 CNA stated she was on duty with a nurse and the night of the fire she was on the floor and saw R20's call light go off. She was walking toward his room when he started to yell FIRE! That made her run into his room where she saw the flames on his bed. V24 stated that R20 had an old electric fan that he had had for a long time. I grabbed him and moved him onto my knees, the nurse brought in the fire extinguisher, and we covered his head while it was in use. The fire department came and that was it. On 3/26/25 at 9:32 AM, V16 Maintenance Director stated he was not aware that he needed to check resident electrical equipment before it goes into service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 9 of 20 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 03/26/2025 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during perineal care for one (R6) resident out of one resident reviewed for perineal care in a sample list of 35. Findings include: R6's undated Face Sheet documents medical diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetic Mellitus, Chronic Multifocal Osteomyelitis, Sacral Pressure Ulcer Stage 4, Anemia, Neuromuscular Dysfunction of Bladder, Urinary Incontinence and Hypokalemia. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. This same MDS documents R6 as being dependent on staff for eating, toileting, bathing, dressing, personal hygiene and transfers. On 3/25/25 at 11: 00 AM V21 and V22 Certified Nurse Aides (CNA) completed perineal care for R6. V22 CNA did not provide a clean field for R6's perineal cleansing supplies. V22 CNA placed R6's wet washcloth and dry washcloth directly on R6's soiled bedside table. R6's bedside table was cleared of items but had several dry liquid spills and unknown pieces of debris. V22 CNA then used the same wet and dry washcloths to cleanse R6's perineal area. On 3/25/25 at 11:20 AM V22 Certified Nurse Aide (CNA) stated she cross contaminated R6's perineal area by not cleaning off R6's bedside table prior to placing the washcloths on it. On 3/25/25 at 2:50 PM V2 Director of Nurses (DON) stated cross contamination during perineal care could cause an infection. V2 DON stated V22 CNA reported to her that V22 had cross contaminated during R6's perineal care. V2 DON stated she gave V22 CNA perineal cleansing education at that time. The facility policy revised 02/12/2025 documents residents who are incontinent of bladder will receive appropriate treatment to prevent infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 10 of 20 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 03/26/2025 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to check the placement of a Gastrostomy tube prior to administering fluids and medication for one of one resident (R40) reviewed for Gastrostomy tubes in a sample list of 35 residents. Findings include: R40's undated Face Sheet documents diagnoses of Cerebral Infarction, Tracheostomy status, Metabolic Encephalopathy, Altered Mental Status, Abnormal Posture, Unsteady on Feet, Reduced Mobility, Muscle Weakness, Intellectual Disabilities and presence of Gastrostomy Tube (G-Tube). R40's Minimum Data Set (MDS) dated [DATE] documents R40 as moderately cognitively impaired. This same MDS documents R40 is dependent on staff for toileting, dressing, personal hygiene, bathing and bed mobility. R40's care plan intervention dated 11/20/24 instructs staff to check the placement of R40's G-Tube for gastric contents/residual volume per facility protocol. On 3/24/25 at 8:05 AM V8 Licensed Practical Nurse (LPN) did not check the placement of R40's Gastrostomy Tube (G-Tube) prior to administering 95 milliliters (ml) of water and protein powder. V8 LPN attempted to use a syringe to administer R40's protein powder which would not flow. V8 LPN attempted to use the syringe to push the protein powder through the G-Tube with no success. V8 LPN then removed the syringe and wasted the protein powder. V8 LPN then checked the placement of R40's G-Tube. On 3/24/25 at 8:30 AM V8 Licensed Practical Nurse (LPN) stated she should have checked the placement of R40's G-Tube prior to administering any type of fluid or medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 11 of 20 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 03/26/2025 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)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop a behavioral plan to address self-harming behaviors for one (R20) of one resident reviewed for behavioral health services from a total sample list of 35 residents. Findings include: The facility provided Behavioral Health Services Policy dated 2/10/25 documents it is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental psychosocial functioning. Additionally, the resident plan of care will maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety. The plan will be reviewed and revised as needed, such as when interventions are not effective or when there is a change of condition. R20's undated diagnosis sheet documents the following diagnoses: Quadriplegia, Urinary Tract Infections, Type II Diabetes Mellitus, Acquired Absence of the Left Upper Limb, Schizophrenia, Depression, Anxiety, Antibiotic Resistance and Multi-Drug Resistant Organisms. R20's Minimum Data Set, dated [DATE] documents R20 as cognitively intact. R20's care plan dated 10/21/21 documents R20 is dependent on staff for all cares. R20's care plan dated 10/20/21 documents R20 has a history of chewing on his right hand and fingers until they bleed. Interventions include antibiotic administration when infection occurs, gloves to hand, education to resident, and placing R20's hand in a sleeve. R20's behavior documentation for the past 28 days documents no chewing behaviors. R20's physician order dated 3/15/25 documents to cleanse the right fingers with soap and water and then dry them thoroughly. Apply a tubular stocking over the hand at bedtime. R20's 2025 psychiatry visits dated 1/13/25 and 2/24/25 do not document anything about R20 self-harming by chewing on his hand. R20's medical record does not contain a level two pre-admission screening and resident review. On 3/23/25 at 10:00 AM, R20's right arm was contracted with the right hand being accessible to R20's mouth. R20 had blood on his right cheek from his cheek to his mouth and the tubular sock has been pulled off and is lying next to R20's hand with blood on it. On 3/25/25 at 9:30AM, V19 CNA stated R20 can still get to the skin with a tubular sock on it. Sometimes they will tie the end in a knot and that makes it even easier for him to pull it off. I got him up this morning, so I know it didn't have a wrap on it. Sometimes he has blood all over his face from chewing it. On 3/23/25 at 1:22 PM, R20's right hand was uncovered and bleeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 12 of 20 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 03/26/2025 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)

F 0740 Level of Harm - Minimal harm or potential for actual harm On 3/23/25 at 1:24 PM, V14 Licensed Practical Nurse (LPN) stated R20 chews his hand all the time and that he's supposed to have a covering on it. On 3/24/25 at 9:10AM, R20's right hand was uncovered with thumb and three fingers bloody and ragged from chewing. No dressing was on R20's hand or fingers and blood was noted on R20's cheek. Residents Affected - Few On 3/24/25 at 9:11AM, V4 Certified Nursing Assistant (CNA) stated that R20 chews on his hand all the time. He can't feel it. On 3/24/25 at 9:14 AM, V3 LPN stated she is unaware of any psych services addressing R20's behavior of biting and that she has told R20 that if he doesn't stop, he will end up having to have his right hand amputated like the left one. On 3/25/25 at 9:35 AM, R20 stated he did not know why he chewed his fingers and that he had never discussed the reason that he chewed his fingers with a doctor, they just tell him not to do it. On 3/25/25 at 2:18 AM, V2 Director of Nursing stated that they currently have no plan for R20's chewing behaviors. On 3/25/25 at 9:00 AM, V2 Director of Nursing stated that she should have been notified of R20's increased behavior of chewing his fingers and that the delay in finding the cause and stopping R20's chewing behaviors has caused R20 harm because he continues to chew on his fingers. On 3/25/25 at 12:08 PM, V23 Nurse Practitioner stated he was aware of R20's chewing but hadn't heard anything about it so he thought it was better. V23 stated, The hand should be covered so that he can't get to it. We didn't really have a plan for it other than covering it and reminding him not to do it. I need to talk to (V31) Medical Doctor and get him a psychiatry referral regarding his chewing so that maybe they can do something about it. Yes, had I known that he was chewing more, I could have done something sooner. He is at risk for infection and if his hand is open that could contribute to his hospitalizations and sepsis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 13 of 20 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 03/26/2025 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer medications according to the physician order for one of seven residents (R90) reviewed for medication administration in the sample list of 35 residents. The facility had three medication errors out of 28 opportunities resulting in a 10.71% error rate. Residents Affected - Few Findings include: R90's Minimum Data Set (MDS) dated [DATE] documents R90 as moderately cognitively impaired. R90's Physician Order Sheet (POS) dated March 2025 documents physician orders for Paroxetine 30 milligrams (mg), Mirtazapine 15 mg and Atorvastatin 40 mg to be administered every bedtime. R90's Medication Administration Record (MAR) dated March 2025 documents R90's Paroxetine 30 milligrams (mg), Mirtazapine 15 mg and Atorvastatin 40 mg were scheduled to be administered at 5:00 PM. On 3/24/25 at 3:20 PM V9 Licensed Practical Nurse (LPN) administered R90's Paroxetine 30 milligrams (mg), Mirtazapine 15 mg and Atorvastatin 40 mg at 3:20 PM. On 3/24/25 at 3:29 PM V9 LPN stated she administered R90's medications early because the two nurses on the fifth floor have to share a laptop computer to use when administering all the resident's medications. On 3/25/25 at 10:15 AM V2 Director of Nurses (DON) stated resident medications should be administered by the physician order. V2 DON stated there was a transcription error when the order was entered into the Electronic Medical Record (EMR). V2 DON stated medications ordered at bedtime should be scheduled at 8:00 PM. The facility policy titled Medication Administration dated 01/04/2025 documents staff are to administer medications according to the physician order. Administer medications within 60 minute prior to or after scheduled time unless otherwise ordered by physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 14 of 20 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 03/26/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure utensils, dishes, and cookware were sanitized prior to serving foods to residents, failed to prevent cross contamination of foods from staff clothing during meal service, and failed to maintain a cooking environment free from debris. This failure has the potential to affect 107 residents residing in the facility. Findings include: The Daily Resident Roster dated 3/23/25 documents 107 reside in the facility. On 3/24/25 at 11:15 AM V29 [NAME] plated resident meals and then passed the plates of food across the food line to the dietary aides. V29's shirt grazed the food in the warmer trays several times when V29 would lean over to pass the plated meal to the dietary aides. On 3/24/25 at 11:30 AM the wall behind and above the food prep area, cooking and fry area had two areas approximately one foot wide and long of peeling paint that was hanging from the wall. These same areas had several pieces of debris that fell into the fryer oil and on top of the food prep area. On 3/24/25 at 11:45 AM V27 [NAME] tested the Ph balance of the facility low temperature dish washing machine three times in a row by placing the litmus strip on the inside wall of the dishwasher during the wash/detergent cycle, prior to the sanitizing cycle. The facility dishwasher sanitizer tubing was connected but not running through the machine. V28 Dietary Manager primed the tubing on the sanitizer. The dishwasher was run again and had the sanitizer circulate through without any difficulty. V28 Dietary Manager then educated V27 [NAME] on how to properly test the Ph balance of the dishwasher and how to test if the sanitizer if working properly. On 3/24/25 at 11:50 AM V27 [NAME] stated he tests the Ph balance of the dishwasher several times per week regularly but was never trained on how to test the PH balance. V27 [NAME] stated he did not know how to see if the sanitizer was running or not. On 3/24/25 at 11:55 AM V28 Dietary Manager stated many of the kitchen staff are newly hired and have not been trained on how to use all the equipment. V28 stated she will provide in servicing on the equipment to all the kitchen staff. V28 Dietary Manager stated all the breakfast dishes were washed without being sanitized prior to serving the residents their lunch meal. V28 Dietary Manager stated serving food on non-sanitized dishes and cookware could cause resident illness. V28 Dietary Manager stated the facility has plans to remodel the facility kitchen including replacing the walls with stainless steel portions behind and above the cooking area. V28 Dietary Manager stated she will have V16 Maintenance Director fix the peeling paint as soon as possible. V28 Dietary Manager stated she will put up plastic guards to protect the foods from being contaminated by staff clothing. V28 stated she will also create a new line system so that the cook does not have to pass the plated meal across the food line. On 3/25/25 at 7:50 AM V16 Maintenance Director stated he is aware that the kitchen wall above the food prep and cooking areas has peeling paint. V16 stated he has already reached out to the facility's corporate office and is waiting for a response to be able to purchase the supplies to fix the wall in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 15 of 20 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 03/26/2025 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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to hold one quarterly Quality Assurance Performance Improvement (QAPI) meeting for the 2024 year and failed to include the facility's Infection Preventionist in all QAPI meetings. This failure has the potential to affect all 107 residents in the facility. Residents Affected - Many Findings include: The facility QAPI sign in sheets dated 2/4/25, 7/12/24 and 4/5/24 does not include an Infection Preventionist documented as attending the QAPI quarterly meeting. The facility is unable to provide documentation of a QAPI meeting being completed for the third quarter (July, August, September) of 2024. On 3/25/25 at 4:00 PM V1 Administrator stated the QAPI meeting is supposed to happen at least quarterly and include the Infection Preventionist. V1 stated she was unable to find any documentation of the facility having a third quarter QAPI meeting for 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 16 of 20 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 03/26/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. R79's Physician Order Sheet (POS) dated March 2025 documents a physician order to administer Azelastine 0.05% eye drops one in each eye twice daily. Residents Affected - Many On 3/23/25 at 3:40 PM V15 Licensed Practical Nurse (LPN) administered R79's Azelastine 0.05% eye drops to R79's eyes. V15 LPN did not wear gloves when administering R79's eye drops. V15 LPN used a tissue to wipe R79's eyes after administering the eye drops then laid the tissue on R79's contaminated bed sheets. V15 LPN stated she did not think R79 got all of his eye drops. V15 LPN then administered another drop to each of R79's eyes and then used the same contaminated tissue to wipe R79's eyes again. On 3/23/25 at 3:50 PM V15 Licensed Practical Nurse (LPN) stated she should have performed hand hygiene and worn gloves prior to administering R79's eye drops. V15 LPN stated she should not have used a soiled tissue to wipe the excess eye drops from R79's eyes. V15 LPN stated these errors could cause an infection in R79's eyes. On 3/25/25 at 10:10 AM V2 Director of Nurses (DON) stated nurses should wear gloves when administering eye drops and use a clean tissue to avoid causing an infection. The facility policy titled Eye Drop Administration dated 10/25/2014 documents staff are to wear gloves when administering eye drops. Wipe off tears or excess solution with clean gauze, cotton ball or tissue. Based on observation, interview, and record review the facility failed to complete a risk assessment plan for Legionella and failed to prevent cross contamination during medication administration. These failures have the potential to affect all 107 residents who reside in the facility. Findings include: The Long Term Care Facility Application for Medicare and Medicaid dated 3/23/25 documents 107 residents reside in the facility. 1.) The facility provided water management program dated 2/1/25 documents it is the policy of this facility to establish water management plans of reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. The facility's Maintenance Director maintains documentation that describes the facility's water system, and a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: Premise plumbing, clinical equipment, at-risk population and the supporting documentation of any areas will be kept in the binder. Based on the risk assessment, control points will be identified. Control measures will be applied to address potential hazards at each point. Testing protocols and control measures will be established for each control measure and the effectiveness of the water management plan will be evaluated at least annually. On 3/26/25 at 9:11AM, V16 Maintenance Director stated he does not have a risk assessment or plan for Legionella, nor any documentation indicating the areas of risk for Legionella growth in the entire facility. He does not have a map of the facility plumbing or testing logs other than on one floor of the building because he was told to do that. V16 stated he is unaware of any Legionella testing in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 17 of 20 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 03/26/2025 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)

F 0880 the past year and stated that he has been told that an outside company is going to take over the Legionella program at the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 18 of 20 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 03/26/2025 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observation, interview and record review the facility failed to employ an Infection Preventionist (IP). This failure has the potential to affect all 107 residents residing in the facility. Residents Affected - Many Findings include: The facility Daily Census dated 3/23/25 documents 107 residents reside in the facility. The Facility Assessment updated 3/17/25 documents the facility resources will include an Infection Preventionist. On 3/23/25-3/26/25 at various times there was no Infection Preventionist on site during the survey timeframe. On 3/25/25 at 4:00 PM V1 Administrator stated the facility does not have anyone in the Infection Preventionist role. On 3/25/25 at 4:05 PM V2 Director of Nurses (DON) stated V2 DON and V20 Regional Director of Clinical Services are both managing the Infection Control Program and neither V2 nor V20 have their IP certificate. V2 DON stated the facility has hired a new IP who will start April 1, 2025 but has not had anyone in the IP role since December 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 19 of 20 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 03/26/2025 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to offer a pneumonia vaccine for one (R352) of five residents reviewed for immunizations from a total sample list of 35 residents. Residents Affected - Few Findings include: The facility Pneumococcal Vaccine Policy dated 12/19/22 documents that it is the policy of the facility to offer immunization against pneumococcal disease. Each resident will be assessed, educated and offered the pneumococcal immunization upon admission. R352's medical record does not document any pneumonia vaccine offered, refused, or given. On 3/26/25 at 10:00AM, V20 Regional Nurse stated that they did not have documentation of R352 being offered, refused or provided a pneumonia vaccine and that was supposed to occur at admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 20 of 20