Loft Rehab of Decatur

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684May 1, 2025

  Failures at this level required more than one Deficient Practice Statement. A. Based on interview and record review the facility failed to immediately notify the physician, complete a pain assessment, complete a physical assessment, and provide pain management when severe pain with redness and swelling to the left knee began suddenly and continued for five days for one (R401) of three residents reviewed for significant change in condition in the sample list of 27. These failures resulted in R401 experiencing severe pain from 3/9/25 to 3/14/25 when R401 was hospitalized with a left femur fracture which required surgical repair. […]

• Immediate jeopardy, isolatedF689Apr 3, 2025

  Based on observation, interview and record review the facility failed to provide adequate supervision/assistance when ambulating a resident to prevent a fall for one of four residents (R2) reviewed for accidents in the sample list of four residents. This failure resulted in R2 falling and suffering a fractured humerus when staff stepped away from R2 to untangle oxygen tubing. Findings include: The Care Plan dated 4/1/25 documents R2 was admitted to the facility on [DATE]. The Care Plan dated 4/1/25 documents R2 was admitted with the following diagnosis: systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, chronic gout, morbid (severe) obesity due to excess calories, polyneuropathy, dependence on renal dialysis, end stage renal disease, cellulitis… […]

• Immediate jeopardy, isolatedF686Mar 7, 2025

  Based on observation, interview, and record review the facility failed to implement repositioning and incontinence cares every two hours, implement pressure relieving interventions, implement pressure ulcer treatments, identify pressure ulcers, monitor and assess pressure ulcers upon identification and weekly, and notify a physician and dietitian of newly identified and current pressure ulcers and deterioration for two (R52, R345) of six residents reviewed for pressure ulcers in the sample list of 48. These failures resulted in R52 developing left heel stage two and right heel stage three pressure ulcers and being hospitalized for an infection of the stage three pressure ulcer. […]

• Immediate jeopardy, isolatedF686Feb 25, 2025

  Based on observation, interview, and record review the facility failed to implement resident centered interventions to prevent skin breakdown and worsening of pressure sores and failed to notify the wound physician and dietician of new open areas for one resident (R2) of three residents reviewed for pressure ulcers in a sample list of five residents. These failures resulted in R2 developing a stage four pressure area to R2's right ischium and unstageable pressure areas to R2's bilateral heels. The Immediate Jeopardy began on 1/20/25 when the original open area was observed to R2's Right Gluteal Fold and the wound nurse practitioner was not notified. V1 Administrator was notified of the Immediate Jeopardy on 2/20/25 at 4:00PM. […]

• Immediate jeopardy, isolatedF678Apr 18, 2022

  Based on interview and record review, the facility failed to ensure a resident's code status, advanced directive, reflected their wishes when they failed to document a discussion with R5 regarding R5's wishes to have a Do Not Resuscitate (DNR) order placed in R5's medical record. The facility also failed to contact R5's physician to obtain a signed DNR order. This failure affects one (R5) of seven residents reviewed for advanced directives in a sample of ten residents. This failure resulted in R5 unnecessarily sustaining Cardiopulmonary Resuscitation on [DATE] at the facility and during transport to a local hospital. R5 expired at the local hospital when CPR (Cardiopulmonary Resuscitation) ceased in accord with R5's wishes. This failure resulted in an Immediate Jeopardy. […]