Loft Rehabilitation & Nursing

F-F882. These failures have the potential to affect all 64 residents residing at the facility.

Findings include:

The facility's Administrator job description, dated June 2021, documents Major duties and responsibilities: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility. Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revision related to the facility's outcomes, regulatory compliance and/or customer satisfaction. Ensures implantation of any and all new policies, procedures, guidance and regulations as directed by the (facility) corporate team. Ensures delivery of excellent customer service and compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially. Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etcetera, are reported to

the correct entity within the stated regulatory requirement. Promotes safe work practices, safety rules, and accident prevention procedures to prevent employee injury and illness.

The facility's Social Services Designee job description, dated June 2021, documents The Social Services Designee will assist the Administrator in the planning, developing, organizing, implementing, evaluating, and directing of social services programs of this facility. The social service designee will meet with administration, medical and nursing staff, and other related departments in planning social services, as directed. The social services designee will assist the administrator in ensuring that staff members are knowledgeable about resident's rights and encourage staff to maintain and enhance each resident's dignity in recognition of each resident's individuality. The social services designee will engage in advance care planning for assigned residents upon admission, and make sure that any advanced directives are reviewed with the resident/resident representative on a regular basis. The social worker will ensure that staff members are made aware of the resident's code status and end of life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications. The social services designee will advocate for residents and assist them in assertion of their rights within the facility. The social services designees will assist with investigations of abuse allegations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 145431 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145431 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530

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 0835 The facility's Facility Assessment, dated 7/24/24, document the facility's provided services and care is based off of residents needs and includes the following roles; Administration, Social Services, Director of Nursing Level of Harm - Minimal harm or and Infection Control and Prevention Specialist. potential for actual harm Resident R315's State Final Report, dated 7/28/24, documents witnessed verbal abuse and intimidation from V17 Residents Affected - Many (Certified Nursing Assistant) to Resident R315 on 7/28/24, was substantiated.

On 7/31/24 at 2:45 PM, V1 (Administrator in Training) stated (V17) will not be allowed to come back to work here. I have not spoken with (Resident R315) yet regarding the incident and wasn't aware that she stated she was scared. We don't have a Social Service Director, so no one has been able to provide psychosocial support for her after the alleged incident on 7/28/24. V1 also verified that she had no record of Abuse Training for (V17) from the facility. V1 stated she has a binder at the nurse's desk that the agency staff reads and signs off on but verified that the abuse policy was not in the binder.

On 7/30/24 at 10:15 AM, Resident R47 stated she had an incident with a nurse (V7, Licensed Practical Nurse) where V7 made her feel afraid to speak to her. Resident R47 stated she ended up being moved to a different room and the former Director of Nursing (V23) acted like it was her fault. Resident R47 stated that V7 still works in the facility and has spoken to her since the incident but they do not get along.

On 7/30/24 at 11:52 AM, V1 (Administrator in training) stated I was aware of the verbal abuse allegation (for Resident R47), but anything medication wise, I let the DON (Director of Nursing) handle. I am aware it was a verbal abuse allegation but (V23) was handling it. At this time V1 confirmed she does not have any abuse documentation, investigation or reported incidents to document any of Resident R47's verbal abuse and intimidation allegations. V1 confirmed she also does not have any documented measures to prevent Resident R47 from being abused, feeling intimidated or feeling scared after the alleged incident.

On 7/29/24 at 12:18 PM, V20 (Resident R12's Family Member) stated she has concerns with the facility not doing what is best for the residents. V20 stated Resident R12 has lived in the facility for several years and lately they have had more problems. V20 stated In the Spring 2024, other family alerted us that (Resident R12) wasn't acting herself. (Resident R12) said she wasn't getting her medications and when I asked about this, the Administrator (in Training, V1) said I don't know what the nurses do. That was all the resolution we received.

On 7/29/24, at 10:40 AM V14 (Registered Nurse) completed a significant medication error after not administering Resident R5's scheduled accucheck and insulin prior to the breakfast meal. V14 went to the nurses station after Resident R5's blood glucose monitoring result was elevated and outside of insulin parameters. V14 stated

she needed to notify Resident R5's provider (V13, Resident R5's Nurse Practitioner). V14 looked around the nurses station and was unable to locate a phone number for V13 for 10 minutes. V14 then picked up the phone to call V1 (Administrator in Training) and stated Today is my first day, I don't know the flow or where things are. I am not sure how to dial out on the telephone. I don't even know what the Administrator (in training) looks like. I don't think (the facility) has a DON. At 10:50 AM, V1 came to the nurses station and also searched for several minutes before locating V13's telephone number for V14 to call.

Resident R52's Medication Administration Record, dated July 2024, documents no administration of Resident R52's Sinemet from 7/25/24 to 7/30/24 or a new physician order to give Sinemet for a total of 5 missed days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 145431 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145431 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530

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 0835 On 7/30/24 at 2:30 PM V2 (Interim Director of Nursing) stated she was unaware that (Resident R52) has not been receiving her Sinemet or that the facility did not call to give Neurology an update and allowed the medication Level of Harm - Minimal harm or order to expire. V2 confirmed this is the second time it has happened. V2 stated, I am unsure what the potential for actual harm nurses are supposed to do when a medication has been missed or a medication error has been made. They should have caught it before hand and called the ordering physician. I would have to look at the Medication Residents Affected - Many Policy to see what the nurses should have done. No medication error report was filled out for the missed doses of Sinemet in June or July 2024.

On 7/30/24 at 1:30 P.M., V1(Administrator in Training) verified that the facility was unable to provide documentation that residents or their representatives have been provided a bed hold policy when residents are sent out to the hospital. V1 stated, We (the facility) currently do not have a Social Service Director and only have an Interim-Director of Nursing, so I am not sure the nursing staff are even aware to give a bed hold policy to resident's when they discharge to the hospital.

On 7/30/24 at 2:15 PM V1 (Administrator in Training) verified Resident R15 and Resident R60's Physician order and POLST (Physician Order for Life Sustaining Treatment) form do not match. V1 stated, Social Services is responsible for ensuring the resident's physician order for advance directives match the resident's current POLST form.

We (the facility) currently don't have a Social Service Director, so I have been trying to help with the advance directives. I have not done an audit to ensure the order and POLST form match to ensure the staff know the appropriate code status for the residents.

On 7/31/2024 at 11:35 PM V1 (Administrator in Training) confirmed that V2 is the Interim Director of Nursing and is filling duties for the facility's Infection Control Preventionist. V1 stated, I was not able to locate the Infection Preventionist certificate.

On 7/31/24, at 11:00 AM, V1 (Administrator in Training) stated she has her temporary Nursing Home Administrator license and started working as the facility's administrator on 8/13/2023.

On 8/1/24 at 11:35 AM, V1 confirmed the facility has several agency nurse and nursing assistants. V1 stated

The nurses on the floor are responsible for reconciling physician orders and making sure they are implementing those. (V2, Interim Director of Nursing) has been helping out as well. When Nurses or CNA's (Certified Nursing Assistants) are agency they are orientated when they come in for their first shift. I orientate now, or the CNA or Nurse that they are working with will. So when a new agency nurse comes here there is

a binder they are to look at and the nurse working with them should train them. Monday (7/29/24) we had two agency nurses (V14 Registered Nurse and V24 Licensed Practical Nurse) and so (V12 Licensed Practical Nurse) was our nurse who should be making sure (V14) was orientated since it was her first day. (V12) was also training (V35, Licensed Practical Nurse) and they were downstairs working on the 600 hall. (V14) was working upstairs. V1 confirmed she was made aware of more abuse concerns this week. V1 stated We have had the two prior abuse citations recently. One was in April and another in June. Both were sexual abuse and the same perpetrator. We talk about Abuse in QAA (Quality Assessment and Assurance) monthly and

we started talking about it more in April with the first Abuse citation we received. We don't have a designated Infection Control Preventionist (ICP), those duties have been completed by the DON. I know they are supposed to be separate roles. We didn't have either the ICP or the DON at our July meeting. In March I think I just wasn't able to be there (QAA meeting) that day and in November we didn't have the Medical Director present (at the QAA meeting).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 145431 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145431 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530

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 0835 The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 documents 64 residents currently reside within the Level of Harm - Minimal harm or facility. potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 145431 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145431 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530

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 38396 potential for actual harm Based on Interview and Record Review, the facility failed to ensure the required members attended the Residents Affected - Many facility's scheduled Quality Assurance meetings. This failure has the potential to affect all 64 residents residing in the facility.

Findings include:

The facility's Facility Assessment, dated 7/24/24, documents the assessment was reviewed on 7/24/24 with

the QAA/QAPI (Quality Assessment and Assurance/Quality Assurance and Performance Improvement) committee.

The facility's QAPI plan, dated 7/3/24, documents The QAA committee will review data from areas the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization. Members of the QAA committee may be added according to the perceived needs of the community, however will have as key members the following positions: Medical Director, Administrator, Director of Nursing, Regional Nurse Consultant, Regional Operations Consultant, Infection Preventionist.

The facility's (undated) Quality Assurance Committee list, provided by V1 (Administrator in Training), does not include an Infection Control Preventionist (ICP).

The facility's QA (Quality Assurance) sign in sheet, dated 7/25/24, documents the Interim Director of Nursing (DON, V2) was not in attendance to the July 2024 meeting.

The facility's QA sign in sheet, dated 3/13/24, documents the only members in attendance to the March 2024 QA meeting were V23 (Former Director of Nursing), V28 (Medical Director) and V34 (former Dietary Manager).

The facility's QA sign in sheet, dated 11/16/23, documents the facility's Medical Director (V28) was not in attendance.

On 8/1/24 at 11:35 AM, V1 (Administrator in Training) confirmed that all required members have attended the quarterly QAA meetings. V1 stated We don't have designated ICP, those duties have been completed by the DON. I know they are supposed to be separate roles. We didn't have either the ICP or the DON at our July meeting. In March I think I just wasn't able to be there that day and in November we didn't have the Medical Director present.

The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 documents 64 residents currently reside within the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 145431 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145431 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530

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 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 33985

Residents Affected - Many Based on record review and interview the facility failed to ensure that they had a qualified Infection Preventionist and failed to obtain the certificate to show the completion of the training. This failure has the potential to affect all 64 resident residing in the facility.

Findings Include:

The Facility Assessment, dated July 24, 2024, documents the following: Training requirements. A facility must develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment.

On 7/30/2024 at 2:23 PM V2/Interim DON (Director of Nurses) stated, I will try to find the certificate to show that I have completed the appropriate infection control training. I didn't see it after I was done with the training. Yes, I just completed most of the training late in the evening yesterday, 7/29/2024 at 6:10 PM. I stayed up last night to try and get it all done. All the training to become an Infection Preventionist was not done prior to your entrance on 7/29/24.

On 7/31/2024 at 11:35 PM V1/Administrator in Training stated, I was not able to locate the Infection Preventionist certificate.

The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 and signed by V1/Administrator in Training, documents 64 residents currently reside within the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 145431