Loft Rehab of Peoria, the

Inspectors wroteBased on interviews and record reviews, the facility failed to implement a comprehensive care plan with interventions for one (R2) resident in five residents reviewed for care plans and failed to prevent abuse for one resident (R1) of four residents reviewed for abuse. This failure resulted in R1 being physically abused with a cane causing a bruise to her neck, nightmares, and exacerbating R1's PTSD (Post Traumatic Stress Disorder) and anxiety. This past noncompliance, which involved R1 and R2, occurred from 5/20/2026 to 5/28/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided and to implement individualized fall prevention interventions for two of three (R1 and R2) reviewed for falls in a sample of three. This failure resulted in R1 sustaining a displaced transcervical left femoral neck fracture, a left iliopsoas hematoma, and a Lumbar 3 vertebral body fracture, and being admitted to the hospital requiring surgical intervention. This failure also resulted in R2 being admitted to the hospital with a subdural hematoma.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation and remove the perpetrator from resident cares while the investigation was underway for one of three residents reviewed for abuse in the sample of six.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of employees to resident verbal abuse to the State Agency for one of three residents (R2) reviewed for abuse in the sample of six.

Inspectors wroteBased on observation, record review, and interview, the facility failed to protect one resident(R2) from abuse of 5 residents reviewed for abuse, in a total sample of five residents. This failure resulted in R1 pulling out his penis and placing his penis on R2's lips. A reasonable person would feel intimidated, stressed, and humiliated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and apply a physician ordered hand protector for contracture prevention, and ensure Range of Motion Services were provided for one (R39) of three residents reviewed for splints and contractures in the sample list of 53.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the resident's physician of a change in condition for one of three residents reviewed for significant change in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to report alleged physical abuse to the State Agency for one of six residents (R1) reviewed for abuse in the sample of six.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drug diversion of a narcotic did not occur for one (R1) of three residents reviewed for narcotic medications in the sample of eight.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide readily available grievance forms, and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 89 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 89 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clip nails for one resident (R66), shave three residents (R40, R62, and R137), and shower one resident (R137) for four of four residents reviewed for ADLs (Activities of Daily Living) in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident call device was within reach for one resident (R66) of 18 residents reviewed for call devices in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of transfer to the hospital to a resident's representative (R8) and failed to notify the facility Ombudsman of resident Discharges/Transfers monthly for three residents (R8, R65, R84) of four reviewed for discharges in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital for one of three residents (R8) reviewed for bed holds in the sample of 33. Findings Include: R8's clinical record documents R8 was hospitalized on [DATE]. R8's clinical record does not contain documentation of written notice of the facility bed hold policy. On 8/22/24, at 3:15pm, V1, Administrator, was unable to produce any documentation the facility's bed hold policy was provided to R8 or R8's representative.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident on a mechanically altered diet was provided supervision at meals as ordered for one (R2) of 18 residents reviewed for meal supervision in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag and tubing were not touching the floor and the urinary bag was covered for one (R2) resident of two residents reviewed for urinary catheters in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place an oxygen sign outside resident bedrooms for two residents (R8 and R14), have a physician order for the cares and administration of oxygen for one resident (R8), and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R18) of three residents reviewed for oxygen therapy in the sample of 33. Findings Include: The Oxygen Policy, dated 5/10/21, documents, Oxygen is administered to residents who need it. Consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility's Oxygen Safety Policy. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of collaboration of care between the facility and the Dialysis center for one of one resident (R66) reviewed for Dialysis in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper PPE (Personal Protective Equipment) was donned and handwashing was performed for one COVID-19 (Coronavirus Disease of 2019) positive resident (R58), and failed to ensure Enhanced Barrier Precautions signage was posted for one resident with an indwelling urinary catheter (R2) of 18 reviewed for infection control in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, failed to develop a care plan and implement interventions for residents at risk for wandering/elopement, and failed to ensure the front door was alarmed for one of three residents (R1) reviewed for elopement risk in the sample of 17. These failures resulted in a cognitively impaired resident (R1) with a known history of wandering, exiting the facility without staff knowledge for 40 minutes until the resident tried to reenter the facility, falling in the mud, and complaining of head and back pain. The facility is located close to a four-lane road that has high activity of traffic. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain scheduled medications from the pharmacy for two of three residents (R2 and R9) reviewed for pharmacy services in the sample of 17. This failure resulted in R9 abruptly stopping and missing his scheduled seizure medication for a minimum of two days resulting in R9 experiencing weakness, seizure, and a fall breaking three ribs. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5-7-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance program.

Inspectors wroteBased on interview and record review, the facility failed to prevent staff to resident verbal/mental abuse for one resident (R11) of four residents reviewed for abuse in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse to the State Agency for one resident (R5) of four residents reviewed for abuse in a sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to develop an oxygen care plan for one (R3) of three residents reviewed for oxygen in a sample of five.

Inspectors wroteBased on interview and record review, the facility failed to process orders for an Iron medication for one (R1) of three residents reviewed for medications in a sample of six.

Inspectors wroteBased on interview and record review, the facility failed to obtain orders/cares for a colostomy for one (R2) of one residents reviewed for colostomies in a sample of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient oxygen for a doctor appointment, and failed to have oxygen orders for two (R1 and R3) of three residents reviewed for oxygen in a sample of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a heel wound, failed to provide treatment orders, and failed to develop a wound care plan for one resident (R5) with a pressure-related heel wound of three residents reviewed for wounds in the sample of seven residents. This failure resulted in an unstageable left heel wound identified on 2/3/24 and without physician treatment orders until 2/14/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two Emergency Carts reviewed were stocked with necessary emergency equipment, and failed to ensure both carts were checked every 24 hours per facility policy. This failure has the potential to affect all 102 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nurse staffing. This failure has the potential to affect all 102 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to administer a narcotic pain medication per order for one (R1) of three residents reviewed for pain in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on a physician authorization request and ensure a physician ordered narcotic medication was available for administration for one (R1) of three residents reviewed for medications in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a urine like smell emanating down two resident hallways, and failed to clean the dining room between meals. This failure has the potential to affect all 98 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to trim nails, shave facial hair, and comb the hair of three residents (R3, R9 and R17), and failed to provide showers to two residents (R2 and R10) out of eight residents reviewed for activities of daily living is a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete dressing changes as ordered by a physician for one resident (R3) out of three residents reviewed for wound care in a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain transmission based precautions for one resident (R10) out of three residents reviewed for transmission based precautions in a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's fingernails were clean and trimmed for one (R1) of three residents reviewed for grooming in a sample of nine.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment. This failure has the potential to affect all 102 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer a resident with a mechanical lift according to a resident's plan of care for one of three residents (R2) reviewed for supervision in the sample of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for four of 14 residents (R5, R13, R14 and R15) reviewed for resident rights in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform handwashing and don PPE/Personal Protective Equipment prior to entering a COVID-19 positive room, and failed to perform hand hygiene upon exiting a COVID-19 positive resident room for ten of 14 residents (R2-R11) reviewed for infection control in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident's privacy and dignity during incontinence care for one of 14 residents (R13) reviewed for resident rights in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for one of 14 residents (R13) reviewed for accommodation of needs in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers (R13 and R14) and shaving assistance (R13) to residents who required assistance with Activities of Daily Living/ADLs for two of three residents (R13 and R14) reviewed for activities of daily living in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weights per facility policy (R13 and R14) and failed to ensure a resident was provided hydration (R13) for two of three residents (R13 and R14) reviewed for dietary needs in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and offer an option of similar nutritive food to a resident who choose not to eat food that is initially served for one of three residents (R13) reviewed for dietary needs in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication for one resident (R88) of three reviewed for closed records in a sample of 37. This failure resulted in resident suffering severe pain and transferring to the hospital for pain control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were wearing name (identification) tags, were not wearing/using cell phone devices during their shift and/or cares, and were treating residents with respect. This has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' meals were served on non-disposable dinnerware. This failure has the potential to affect all residents who consume food in the facility, except R58, R191, and R344, who are NPO (nothing by mouth).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items were stored and labeled with dates and identification. This failure has the potential to affect all residents who consume food in the facility, except R58, R191, and R344 who are NPO (nothing by mouth).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents felt safe and comfortable when reporting any concern or grievance to the facility for five of five residents (R4, R6, R13, R60, and R70) reviewed during resident council in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide daily personal hygiene/grooming care for four residents (R18, R22, R23 and R58), failed to provide incontinence care to prevent over saturation of an incontinence brief for one resident (R46), and failed to change visibly soiled linen for one resident (R13) out of six residents reviewed for activities of daily living in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were implemented for two (R23 and R46) of five residents reviewed for falls, and failed to follow the facility smoking policy for three (R17, R37, and R76) of four residents reviewed for smoking in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents took their medications for two (R56 and R76) of two residents reviewed for self administration of medications in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within resident reach for two (R38 and R46) of 19 residents reviewed for call light's in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to internally report an alleged case of verbal/emotional staff to resident abuse for one of four residents (R13) reviewed for abuse in a sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to investigate an alleged case of verbal/emotional staff to resident abuse for one of four residents (R13) reviewed for abuse in a sample of 37.

Inspectors wroteBased on record review and interview, the facility failed to perform blood glucose monitoring for one diabetic resident (R343) of three reviewed for glucose monitoring in a total sample of 37. Findings Include: R343's Medical Record documents she was admitted on [DATE], with a diagnosis of Type 2 Non Insulin Dependent Diabetes. R343's Admitting Physician's Order, dated 4/5/23, documents, Give Glimerpride 1 mg (milligram) daily for Type 2 Diabetes. R343's Physician Order Sheet, dated 4/6/23, documents, Check blood sugar every morning. R343's Medication Administration Record for April 2023 documents blood sugar monitoring started on 4/13/23. On 6/1/23, V2 (Director of Nursing) stated, Yes, we missed her accucheck (blood glucose monitoring) for a week when she was admitted . We should have caught that and been doing them since 4/13/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion (ROM) exercises to prevent further contracture for one resident (R32) out of five residents reviewed for limited range of motion in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent residents receive incontinence care in a timely manner for one (R13) of two residents reviewed for bowel and bladder incontienece, and failed to ensure indwelling urinary catheters were secured in a way to prevent cross contamination for two (R23 and R58) of two residents reviewed for urinary catheters in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for gastronomy tube (G-tube) dressing change for one resident (R22) out of two resident reviewed for tube feedings in a sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident mail was delivered Monday through Saturday. This has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Assessment (QAA) meetings were held at least quarterly. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion and mobility programs for residents with identified limitations of range of motion and mobility for eight of ten residents (R22, R23, R25, R32, R33, R40, R52, R56) reviewed for range of motion/mobility in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reconcile controlled medications for 10 of 10 residents (R41, R42, R226, R227, R327, R328, R329, R330, R333 and R334) reviewed for medications, in the sample of 33.

Inspectors wroteBased on interview, record review, and observation, the facility failed to check for gastrointestinal placement, residual, and elevate the head of the bed to a 30 to 35 degree angle for one resident (R32) of two reviewed for gastrostomy tubes in a sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to document diagnoses for the use of antipsychotic medications, failed to document and track target behaviors for the use of antipsychotic medications and failed to ensure residents exhibited behaviors that warrant the use of an antipsychotic medication for three of three residents (R24, R25, R52) reviewed for antipsychotic medications in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for one resident (R41) on the sample of three residents reviewed for medication pass. This failure resulted in four medication errors out of thirty three opportunities, for a 12.12% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a physician's ordered diet for one of two residents (R330), reviewed for specialized diets, in a sample of 33 . R330's facility admission Record documents R330 was admitted to the facility on [DATE] from a local hospital with the following diagnoses: Fracture of the Left Hip and Pneumonitis due to Inhalation of Food. R330's admission Speech Therapy Treatment Note, dated 4/1/22, documents, Risk for aspiration with thin liquids. Currently receiving antibiotics for aspiration pneumonia. Continue Pureed diet with thickened liquids. R330's Nursing admission Assessment, dated 4/1/22, documents: Section G. Nutrition/Oral Status: No special needs or considerations. R330's admission Care Plan, dated 4/1/22, includes the following Focus and Interventions: Resident DIET IS GENERAL/REGULAR/REGULAR LIQUIDS. [...]