Loft Rehabilitation & Nursing

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 28, 2023

  Based on observation, interview and record review, the facility failed to supervise a moderately cognitively impaired high fall risk resident with known wandering and exit seeking behaviors, failed to ensure exit door alarms were on and activated at all panels in the facility to ensure the alarm could be heard throughout the facility, and failed to ensure a facility exit door that contained the facility's electronic wandering door management system was completely closed allowing the electronic wandering door management system to work as designed. These failures resulted in R1 exiting the facility without staff knowledge through two separate facility exit doors. […]

• Immediate jeopardy, patternF610Apr 14, 2022

  Based on observation, interview and record review, the facility failed to immediately supervise a confused, wandering resident (R34) with a history of aggressive behaviors and implement new interventions after a resident to resident (R34 and R51) physical altercation occurred and failed to protect residents in the facility, including (R7, R31,R36, R46, R39, R51) who reside on the same hallway as R34, from further abuse and potential abuse during the course of an open investigation. This failure resulted in R34 having continued access to residents in the facility, including R31 who R34 physically pulled and shoved hours after R34's previous altercation with R51 on 3/19/22. This failure also resulted in R34 and R51 continuing to have bedrooms that were connected with a shared bathroom. […]

• Immediate jeopardy, patternF610Sep 21, 2021

  Based on interview and record review the facility failed to recognize and investigate an allegation of seclusion as possible abuse for one (R1) of six residents reviewed for abuse in a sample of six. This failure resulted in the facility not readily initiating an investigation which further led to the alleged perpetrator continuing to work in the facility and care for R1 and further subjecting all other residents (R5 and R7- R14) who came in contact with the alleged perpetrator to potential abuse. This failure resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689Feb 25, 2026

  Based on observation, interview and record review, the facility failed to ensure adequate supervision and prevent an intermittently confused resident from exiting the facility, unannounced to staff, through alarmed exit doors after a visitor silenced the door alarm without staff knowledge. Staff failed to monitor the alarm system and failed to recognize the resident's elopement. The resident exited the building unsupervised, during freezing temperatures, wearing only a tee shirt and sweatpants. Approximately 13 minutes later, the resident was discovered by a patrolling police officer in the facility parking lot, adjacent to an access road used by residents of a nearby apartment complex, creating a high risk for traffic- related injury. […]

• Immediate jeopardy, isolatedF689Sep 25, 2024

  Based on observation, interview, and record review the facility failed to ensure all facility door alarms sounded loud enough for immediate staff response, immediately search the premises for a resident once a door alarm was heard sounding and provide adequate supervision to a cognitively impaired resident with a history of exit seeking for one of three residents (R1) reviewed for elopement risk in the sample of five. These failures resulted in R1, a severely cognitively impaired resident with the diagnosis of Dementia, exiting the facility without staff knowledge or supervision on 9-10-24, walking over 1635 feet down a hill, falling by a tree that was located approximately 25 feet from a main street, causing R1 to sustain two fractures to the end of the forearm (at the wrist),… […]