Health inspection·April 7, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ulcer measurements are 5.5 cm x 4.5 cm x 2.2 cm. V4 documents the wound had moderate foul-smelling drainage and documents she manually removed a moderate amount of dead fat tissue from R2's pressure ulcer and that R2 appears to be declining. V4 documents new orders to apply Santyl once daily for 16 days to the wound bed; Sodium hypochlorite solution (Dakin's) apply to the wound bed twice daily for 30 days. Soak gauze dressing with .0125% Dakin's solution, wring out the gauze and apply to the wound bed only, twice daily for one week, until 2/26/25. If the wound is improved by 2/26/25, stop Dakin's and apply alginate silver once daily to the wound bed. R2's Wound Evaluation and Management Summary dated 2/25/25 documents R2's coccyx pressure ulcer is now a Stage 4 pressure ulcer measuring 3.7 cm x 3.2 cm x 2.5 cm. This same evaluation documents to discontinue the order for Santyl daily to the coccyx and start a new order for Sodium hypochlorite solution (Dakin's) apply to the wound bed twice daily for 30 days. Soak gauze dressing with .0125% Dakin's solution, wring out the gauze and apply to the wound bed only, twice daily. This evaluation further documents a new order for Tetracycline 500 milligrams twice a day, for 14 days for treatment of cellulitis to the coccyx wound. R2's Wound Evaluation and Management Summary dated 3/5/25 documents R2's coccyx pressure ulcer measurements were 3.4 cm x 4.2 cm x 1.5 cm with 6 cm of tunneling in the wound bed. The same evaluation further documents R2's coccyx wound is odorous, with heavy drainage and the wound tunneling has worsened with grayish/black drainage. V4 documents to continue with the same wound treatment order and oral antibiotics. This same evaluation further documents V4 manually removed black, dead tissue from the wound bed with a surgical blade. R2's Wound Evaluation and Management Summary dated 3/12/25 documents R2's coccyx pressure ulcer measurements were 2.9 cm x 3 cm x 1.5 cm with 4 cm of tunneling. V4 further documents a moderate amount of odorous drainage from wound bed. The same evaluation documents V4 manually removed dead tissue from the wound bed using a blade during assessment. V4 documents to continue the same treatment order to R2's coccyx pressure ulcer. R2's Wound Evaluation and Management Summary dated 3/19/25 documents R2's coccyx pressure ulcer measurements were 4.5 cm x 4.5 cm x 1.5 cm with 5.5 cm of tunneling. This same assessment documents R2's wound has heavy, grey, foul-smelling drainage coming from the wound with increased black, dead tissue to the wound bed which was manually removed with a blade. V4 documents to continue with the same treatment to the pressure ulcer and start Ciprofloxacin 500 milligrams by mouth, for 14 days for wound infection, and Flagyl 500 milligrams, crush and sprinkle into wound base, twice daily with dressing changes. R2's Wound Evaluation and Management Summary dated 3/26/25 documents R2's coccyx pressure ulcer measurements were 3 cm x 5 cm x 1 cm with 6.1 cm of tunneling. V4 documents R2's coccyx pressure ulcer still has moderate amounts of black dead tissue covering the wound bed, heavy drainage, and the wound tunneling is now opened at sacral area as well. V4 documents V4 manually removed dead skin tissue using a blade. This same evaluation documents to continue with the same wound treatment started on 2/19/25. On 4/2/25 at 10:00 AM, R2 is lying supine in bed on a perimeter mattress with no low air loss mattress, wearing a hospital gown. On 4/2/25 at 12:13 PM, R2 is lying in her bed supine with a hospital gown on. R2 stated she often has pain in her coccyx area and her feet. R2 stated she has a wound on her buttocks but was not sure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 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 146003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2025 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)

F 0686 how it started. Level of Harm - Minimal harm or potential for actual harm On 4/2/25 at 1:15 PM, R2 has two separate stage four pressure ulcers on coccyx that are merging into one pressure ulcer. The original coccyx pressure ulcer is open and covered in yellow/gray tissue over the wound bed. The second pressure ulcer is on the left upper buttocks and is open with a red wound bed. Between the two wounds is a small layer of skin. The wound tunnels into R2's coccyx. V4 measured the tunneling to be 6 cm. There was a large amount of yellow and pink drainage on the adhesive bandage that was removed from R2's wound. Residents Affected - Few On 4/2/25 at 1:05 PM, V4 stated R2 is supposed to be on a low air loss mattress to help with pressure distribution for wound healing. V4 stated R2 could probably benefit from having Negative Pressure Wound Therapy due to the increased amount of drainage from the wound, but V4 does not have much knowledge with using Negative Pressure Wound Therapy (wound vac). R2's Wound Evaluation and Management Summary dated 4/2/25 documents R2's coccyx pressure ulcer measurements were 4.5 cm x 8.3 cm x 2.5 cm with 6 cm of tunneling. V4 manually removed yellow colored dead skin with a blade that was covering the wound bed and documents a new order to place a Negative Pressure Wound Therapy on R2's coccyx due to increased amount of drainage to the wound site. On 4/2/25 at 1:00 PM, V3 Wound Nurse stated R2 is supposed to be on a low air loss mattress and the mattress she is on currently is not correct. V3 further stated that R2 had moved rooms over the weekend and the staff didn't move R2's low air loss mattress. On 4/2/25 at 2:00 PM, V1 Administrator and V2 Director of Nursing stated they would expect after two weeks of a wound not making progress that a new treatment would be ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146003 If continuation sheet Page 3 of 3