Loft Rehab & Nursing of Normal

In the surveyor’s words

From the most serious findings on record at Loft Rehab & Nursing of Normal, in the surveyor’s own words.

• Immediate jeopardy, patternF760Sep 27, 2023

  Failures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to accurately transcribe hospital discharge medication orders for a resident (R37) with a seizure disorder, ensure medications were available for administration, and ensure contracted nurses have access to the backup medication supply. These failures resulted in R37 missing 13 doses of medications to control seizures: 9 doses of Divalproex Sodium, 2 doses of Levetiracetam and 2 doses of Carbamazepine; being hospitalized experiencing continued seizures and requiring intravenous seizure medication. R37 is one of three residents reviewed for hospitalization s in the sample list of 47. […]

• Immediate jeopardy, isolatedF689Aug 5, 2024

  Based upon observation, interview and record review, the facility failed to ensure for the safety and supervision of a resident with a history of self-harm and attempts at suicide. These failures affect one (R1) of three residents reviewed for behavioral health services on the sample list of three. R1 put a plastic bag tightly over R1's head resulting in emergency transport to the hospital, previously R1 was found on 5/20/24 with the call light cord wrapped around her neck. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/20/24 when R1 was found with the call light cord wrapped around R1's neck. R1 had continued access to self-harm items resulting in another attempt on 7/10/24. […]

• Immediate jeopardy, isolatedF689Jun 24, 2024

  Based on interview and record review the facility failed to ensure a severely cognitively impaired resident (R1) did not exit the facility unnoticed (elopement). The facility failed to reassess and develop a plan of care for a resident with a known history of exit seeking behaviors, wandering, and supervision needs during emergency procedures. These failures affect one (R1) resident reviewed for elopement on a sample list of three residents. These failures resulted in R1 exiting the facility in the late afternoon on 5/31/24, unsupervised, being found 17 hours later in a grassy area next to a creek. […]

• Actual harm, patternF692Sep 27, 2023

  Based on observation, interview and record review, the facility failed to maintain a resident's nutritional and hydration status to prevent a significant weight loss and dehydration. The facility failed to: follow physician orders for monitoring enteral feeding (via gastrostomy tube) intake amounts for a resident who has care orders for nothing by mouth and ensure for placement of the resident's abdominal binder. The facility also failed to follow up with the physician and implement dietary recommendations or notify the Registered Dietician and/or Physician of the inability to obtain the recommended enteral feedings in a timely manner. […]

• Actual harm, isolatedF684May 17, 2026

  Based on observation, interview and record review the facility failed to obtain admission orders from the hospital upon admission, failed to complete a timely admission assessment and wound assessment, failed to timely administer medications for the treatment of a leg infection, diabetes, hypertension and other comorbidities and failed to provide mobility devices. The facility also failed to implement physical and occupational therapy evaluations upon admission which resulted in R1 having to stay in bed and use a bedpan for toileting needs. These failures affected one (R1) of three residents reviewed for admissions in the sample list of nine. These failures resulted in R1 sustaining ongoing, significant emotional distress, tearfulness and fear of a delayed recovery. […]