Cobalt Lodge Health Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Cobalt Lodge Health Care and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 8, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Resident #8 and #4) who were identified to be at risk for elopement, the facility failed to develop a care plan and implement interventions when it was identified that Resident #8 was at risk for elopement and failed to implement their Elopement policy when the resident was discovered missing. The failures resulted in the finding of Immediate Jeopardy. For Resident #4 who was at risk of elopement, the facility failed to ensure a Wanderguard alarmed door was shut and latched completely to prevent the resident from exiting out the door and into the parking lot, subsequently falling and sustaining injuries. […]

• Actual harm, isolatedF689Jun 3, 2026

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #8) reviewed for accidents, the facility failed to ensure a safe transfer via a hoyer lift when the hoyer lift got caught under the wheelchair and was jerked by a nurse aide causing Resident #8 to fall from the wheelchair to the floor. As a result, Resident #8 sustained an acute L5 endplate fracture (a break in the top or bottom cartilage layer of the L5 vertebra). […]

• Actual harm, isolatedF689Sep 29, 2025

  Based on a review of clinical records, facility documentation, policy, and staff interviews for one of three sampled residents (Resident #1) who was dependent on staff for transfers and toileting, the facility failed to ensure the nurse aide care card was updated to reflect the resident's current non-ambulatory status. This lapse resulted in a fall with significant injury to Resident #1, who was then treated for a traumatic subarachnoid hemorrhage (internal bleeding into the space between the brain and the membranes that cover it), a right femoral neck fracture (broken thigh bone that required surgery), and a right distal clavicle fracture.The findings include:Resident #1's diagnoses included unsteadiness on feet, polyneuropathy, atrial fibrillation, and cognitive communication deficit. […]

• Actual harm, isolatedF600Sep 8, 2025

  Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #7) who were reviewed for an allegation of abuse, the facility failed to ensure the resident was free from physical abuse when the resident's behavior escalated and a staff member pushed the resident to the floor resulting in a fracture. The findings include:Resident #7's diagnoses included vascular dementia with psychosis (condition where cognitive decline caused by damage to blood vessels in the brain is accompanied by psychotic symptoms) and major depressive disorder. […]

• No harm, potential for more than minimal, widespreadF947Sep 8, 2025

  Based on review of facility documentation, facility policy and interviews for five (5) sampled Nurse Aides (NA #6, #7, #8, #9 and #10), the facility failed to ensure the nurse aides received at least twelve (12) hours of in-service training annually. The findings include:Review of NA #6, #7, #8, #9 and #10's personnel files failed to reflect documentation the nurse aides received annual in-service training. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on [DATE] at 10:00 AM identified the facility has been without a Staff Development Coordinator since [DATE], stating she was terminated for not completing requirements of the job. […]