Loft Rehab & Nursing Of Normal

F 0550 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on the floor and needed help. V21 Activity Director stated she went to Resident R3's room found her lying on the floor partially on a fall mat, not covered up, with a pillow behind her back, and Resident R3's head was leaning against the wall.On 11/25/25 at 10:35 AM, V11 Licensed Practical Nurse (LPN) stated she was the nurse coming on duty the morning Resident R3 was found on the floor. V11 LPN stated V1 Administrator came to V11 LPN and asked V11 LPN why Resident R3 was on the floor. V11 LPN stated V7 RN did not tell V11 LPN that Resident R3 was found on the floor during the night. On 11/24/25 at 2:36 PM, V17 CNA stated she overheard V1 Administrator on the morning of 11/20/25 loudly addressing staff after finding Resident R3 lying on the floor saying, what if this was your family member that was left lying on the cold floor?On 11/25/25 at 9:49 AM, V1 Administrator stated she found Resident R3 floor in Resident R3's room around 6:55 AM. V1 Administrator stated Resident R3 was partially lying on a fall mat, not covered, and was not arousable. V1 stated this was unacceptable that the nurse should have assessed Resident R3 immediately when the unwitnessed fall was reported and gotten Resident R3 up off the floor and into her bed. On 11/25/25 at 2:43 PM, V24 (Resident R3's) Husband tearfully stated if Resident R3 had the ability to communicate on 11/20/25 when Resident R3 was found on the floor, Resident R3 would have been anxious, pissed off and questioning how she got on

the floor and why she was left there. The facility's Resident Right's Policy dated 2/12/25 documents that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This policy documents the following:2. Exercise of rights. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.9. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehab & Nursing of Normal

510 Broadway Normal, IL 61761

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

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** Based on

interview and record review the facility failed to ensure a resident was properly supervised to prevent a fall for one (Resident R3) of three residents reviewed for accidents on a sample list of five. Findings include:Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documents that Resident R3 was not able to complete the Brief Interview for Mental Status (BIMS) due to cognitive impairment.Resident R3's admission fall risk assessment dated [DATE REDACTED] documents Resident R3 is at risk for falls.Resident R3's Care Plan dated 10/23/25, documents that Resident R3 is at risk for falls related to dementia, side effects of medication and a terminal condition.Resident R3's Care Plan dated 10/30/25, documents that Resident R3 is an elopement risk/wanderer related to Resident R3 is disoriented to place and has impaired safety awareness.Resident R3's progress notes document that on 11/20/25 at approximately 6:00 AM Resident R3 was observed on

the floor in Resident R3's room.On 11/25/25 at 12:40 PM, V18 Certified Nurse Assistant (CNA) stated V18 sat right outside of Resident R3's room the night of her unwitnessed fall. V18 stated V18 went on her lunch break sometime

during the middle of the night and when she returned V19 CNA told her that Resident R3 was found on the floor in Resident R3's room. V18 CNA stated that she got Resident R3 off the floor around 4:30 AM to toilet Resident R3 and then left Resident R3 sitting

on the edge of Resident R3's bed. V18 CNA stated that around 6:00 AM while doing change of shift rounds Resident R3 was found lying on the floor again next to Resident R3's bed.On 11/25/25 1:11 PM, V19 CNA stated that she found Resident R3 on

the floor and reported it to V7 RN and V7 told V19 CNA to leave Resident R3 and the floor. V19 CNA stated V7 RN did not go to Resident R3's room to assess Resident R3 after being found on the floor.On 11/25/25 at 2:51 PM, V7 Registered Nurse (RN) stated she was the nurse on duty at the time of Resident R3's fall on 11/20/25 and that V7 RN went on lunch break around 12:50 AM and when she returned V19 CNA told V7 that Resident R3 was found on the floor. V7 RN stated that V8 Licensed Practical Nurse (LPN) told V7 RN in shift report that Resident R3 would sometimes put herself on the floor and that it would not be considered a fall. V7 RN stated V7 RN made a mistake in not documenting the unwitnessed fall. On 11/25/25 at 9:49 AM, V1 Administrator stated that V1's expectation of

the staff was that they should have partnered with their coworkers to keep a close eye on Resident R3 to prevent falls and keep Resident R3 safe and comfortable. The facility's fall policy dated 2/12/25 documents that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: a fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The nurse will indicate on the Fall Risk Assessment/Morse Fall Assessment the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. This policy documents that the facility will provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status and provide additional interventions as directed by the resident's assessment, including but not limited to: assistive devices, increased frequency of rounds, sitter, if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education and therapy services referral.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehab & Nursing of Normal

510 Broadway Normal, IL 61761

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 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to ensure a resident was kept free from a significant medication error for one (Resident R3) of three residents reviewed for medication management on a sample list of five residents. Findings include:Resident R3's Electronic Medical Record (EMR) contained a physician's order dated 10/22/25 documenting that Resident R3 was to receive Haloperidol (HALDOL) two milligrams (mg)/ milliliter (ml) concentrate, take one ml by mouth every eight hours for agitated movements accompanied by emotional distress. Resident R3's physician orders in Resident R3's EMR dated 10/22/25 document an order for Haloperidol Lactate Oral Concentrate two mg/ml, give two ml by mouth every eight hours for agitation/restlessness.Resident R3's October and November 2025 Medication Administration Record (MAR) documents that Resident R3 received seventy-three incorrect doses of Haloperidol. Resident R3's EMR contains a letter dated 11/20/25 documenting that V2 Assistant Director of Nursing (ADON) reported Resident R3's Haloperidol medication error to Physicians Group. This letter documents that Resident R3 was lethargic that day. On 11/25/25 at 12:02 PM, V2 Assistant Director of Nursing (ADON) stated V3 [NAME] President of Clinical Services did a medication audit after Resident R3's unwitnessed fall and found that Resident R3's physician order for Haloperidol two mg/ml, give one ml every eight hours was transcribed incorrectly as Haloperidol two mg/ml, give two ml every eight hours. V2 ADON stated validation by a second nurse is not facility policy but V2 ADON thinks it should be. On 12/01/25 at 10:00 AM, V3 [NAME] President of Clinical Services stated the nurse that incorrectly transcribed Resident R3's physician's order for Haloperidol has been terminated and that an unwritten policy of the facility is that a second nurse should validate the physician's order that were entered into a resident's chart. V3 stated validation by a second nurse should have been done. The facility's Physician/Practitioner Orders Policy dated 2/10/25 documents that the attending physician shall authenticate orders for the care and treatment of assigned residents. This policy documents the following explanation and compliance guidelines: 2. for physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. if not the attending, call the attending physician to verify the order and b. follow facility procedures for verbal or telephone orders including noting

the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet