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Complaint Investigation

Loft Rehab & Nursing Of Normal

January 2, 2026 · Normal, IL · 510 Broadway
Citations 4
CMS Rating 1/5
Beds 116
Provider ID 145031
Healthcare Facility
Loft Rehab & Nursing Of Normal
Normal, IL  ·  View full profile →
Inspection Summary

LOFT REHAB & NURSING OF NORMAL in NORMAL, IL — inspection on January 2, 2026.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to answer call lights in a timely fashion for three of three residents (R2, R7, R10) reviewed for call lights in the sample list of eleven.Findings Include:Grievance logs dated October 2025, November 2025 and December 2025 all document residents having to wait extended times for help with various activities.Resident Council Minutes dated 12/3/25 document 13 residents attended the meeting and documented staff need to answer call lights quicker.R2's Medical Record reviewed 12/30/25 documents R2 admitted to the facility on [DATE] from a local hospital with Diagnoses of Weakness, Right Sided Hemiparesis, Cognitive Decline, B12 Deficiency, Back Pain, Right Lower Extremity Pain, Microscopic Hematuria, Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Vascular Accident, and Multiple Sclerosis. R2's medical record does not contain an admission assessment or admission note from a licensed nurse from time of arrival until discharge. On 12/30/25 at 10:20am V4, R2's Family, stated that R2 did not have a call light but rather a call bell that was rang several times and went without any staff members answering the sound of the bell.On 12/30/2025 R7's Care Plan dated 11/26/25 documents R7's admission to the facility on [DATE] with the following diagnoses: Aphasia Following Cerebral Infarction, Dysarthria Following Cerebral Infarction, Apraxia Following Cerebral Infarction, Pulmonary Hypertension, Atrial Fibrillation, and Benign Prostatic Hyperplasia.

The Minimum Data Set, dated [DATE] documents R7 is cognitively impaired.On 12/30/25 at 11:20am R7 stated the call light system works, though once activated it has taken anywhere from 30min to two hours to get a response from staff.On 12/30/2025 R10's Care Plan dated 11/27/25 documents R10's admission to the facility on [DATE] with the following diagnoses: Abnormal Levels of Other Serum Enzymes, Lichen Simplex Chronicus, Malaise, Hyperlipidemia, Muscle Wasting and Atrophy, Specified Disorders of Muscle and Lack of Coordination. R10's Minimum Data Set documents R10 is cognitively intact.On 12/30/25 at 1:00pm R10 stated call light response time can vary but have been as long as two hours.On 1/2/26 at 12:45pm V16, Corporate Nurse, stated staff should answer the call light in under 10 minutes.On 1/2/26 at 1:05pm V19, DON, stated staff should answer the call light in under 10-15 minutes to meet resident needs.

The Call Lights: Accessibility and Timely Response policy dated 2/06/25 documents: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance.

Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Policy Explanation and Compliance Guidelines: 9.

Process for responding to call lights: a.

Response times should be a priority.

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/02/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehab & Nursing of Normal

510 Broadway Normal, IL 61761

SUMMARY STATEMENT OF DEFICIENCIES

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R8 and R9) reviewed for abuse in the sample list of eleven.Findings Include:On 12/30/25 the facility provided an investigation file dated 12/2/25 documenting a physical incident occurred between two roommates/residents (R8, R9).

The file documents staff responded immediately, intervening to stop the interaction and separate the residents.R8's Current Care Plan reviewed on 12/30/2025 documents R8's admission to the facility on 5/1/2025 with the following diagnoses: Metabolic Encephalopathy, Protein-Calorie Malnutrition, Anemia in Chronic Kidney Disease, and Dementia in other Diseases, Moderate, with Agitation.R8's Minimum Data Set, dated [DATE], documents R8 with a brief interview for mental status score of 14 indicating R8 is cognitively intact. R8's Care Plan dated 06/27/2025 addresses wandering without purpose and wandering into other resident's spaces.R9's Current Care Plan reviewed 12/30/2025 (DOB 6/21/63) documents R9's admission to the facility on 1/30/2025 with the following diagnoses: Retention of Urine, Primary Generalized Osteoarthritis, Mild Intermittent Asthma, Recurrent Left-Shoulder Dislocation, and Disorders of Bone Density/Structure.R9's Minimum Data Set, dated [DATE] documents R9 with a brief interview for mental status score of 3 indicating cognitive impairment. R9's care plan dated 10/06/2025 documents Behavioral Symptoms are present.V14's (Activity Aide) statement dated 12/8/2025 documents R9 and R8 exchanged words then V14 removed R8 and R8 put himself back in and the two began engaging hits to one another.V9's (Certified Nursing Aide) statement dated 12/8/2025 documents V9 heard yelling from the room, as V9 was making her way there to separate the residents the activity aide (V14) stated R8 and R9 had been kicking each other. V15's (Licensed Practical Nurse) statement dated 12/8/25 documents R8 engaged in an altercation with R9 in their room.On 12/30/2025 at 11:02 AM R8 was unavailable for interview due to being transferred from the dialysis clinic to the acute care hospital for further care.On 12/30/2025 at 11:37 AM R9 stated he had a physical altercation with his old roommate, R8. R9 stated R8 hit him so R9 hit him back.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/02/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehab & Nursing of Normal

510 Broadway Normal, IL 61761

SUMMARY STATEMENT OF DEFICIENCIES

Provide care and assistance to perform activities of daily living for any resident who is unable.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers for three (R1, R3 and R6) of five dependent residents reviewed for activities of daily living out of a sample list of eleven.Findings Include:R1's current Medical Record documents R1's admission to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis Right Ankle and Foot, Weakness, Chronic Atrial Fibrillation, and Chronic Kidney Disease Stage Four. R1's Care Plan includes a focus regarding ADL deficits initiated 04/11/2025.

R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.On 12/30/2025 at 9:42 AM R1 stated he received a bed bath last night with water staff retrieved from another area of the facility. R1 stated he had not received a shower or bed bath for approximately two weeks prior to last night's bed bath.

R1 described his bed bath water as lukewarm. R1 stated the hot water has not been working for a couple of months and that the lack of hot water is the entire uptown hall. R1 stated the other half of the facility called Downtown has hot water for use.R3's current Medical

Record review documents R3's admission to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Acute and Chronic Respiratory Failure with Hypoxia, and Type Two Diabetes Mellitus with Diabetic Neuropathy. R3's Care Plan includes a Care Plan focus regarding R3 having an ADL self-care performance deficit related to Fatigue, Impaired balance and Limited Mobility that was initiated 02/21/2024.R3's MDS dated [DATE] documents R3 is moderately cognitively impaired.On 12/30/2025 at 9:52 AM R3 stated she does not get two showers a week every week. R3 stated she gets showers that are warm to touch.R6's Current Medical

Record review documents R6's admission to the facility on [DATE] with the following diagnoses: Fracture of Upper and Lower End of Left Fibula, Repeated Falls, and Disorders of Muscle. R6's Care Plan dated 12/18/25 documents a Care Plan focus regarding ADL self-care performance deficit related to upper and lower left fibula fracture initiated 12/18/2025.On 12/30/2025 at 10:13 AM R6, with the use of a dry erase board and marker, wrote the facility has been experiencing lack of hot water, on her hall, for over a month. R6 communicated she is taken to another part of the facility to shower where there is hot water available for use. R6 communicated she doesn't feel that she gets enough showers at this facility.On 1/2/2026 at 1:30 PM V16, Corporate Nurse, stated residents are to be receiving two showers weekly and not all residents are getting the showers as required. V16 stated V16 was unable to provide correct documentation of dates the residents' received showers.The Activities of Daily Living (ADLs) policy dated 2/10/2025 documents: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:1.Bathing, dressing, grooming and oral care.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene and oral hygiene.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/02/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Loft Rehab & Nursing of Normal

510 Broadway Normal, IL 61761

SUMMARY STATEMENT OF DEFICIENCIES

white correction tape. V16 confirmed the signatures on the shower sheets provided were inconsistent with the same dated assignment sheets. V16, confirmed the shower sheets provided were inaccurate.1.The Documentation in Medical Record policy dated 09/01/25 documents: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Policy Explanation and Compliance Guidelines: 1.

Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2.

Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NORMAL, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LOFT REHAB & NURSING OF NORMAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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