Loft Rehabilitation & Nursing: Leadership Failures - IL
The administrator-in-training acknowledged this herself. On July 31, 2024, she told inspectors: "I have not spoken with her yet regarding the incident and wasn't aware that she stated she was scared. We don't have a Social Service Director, so no one has been able to provide psychosocial support for her after the alleged incident on 7/28/24."
The state had already substantiated the abuse. The CNA, identified in the report as V17, would not be allowed back. But the resident, identified as R315, sat in that building with her fear and no one assigned to address it.
That gap, no social services director, was not the only vacancy. The facility also had no permanent Director of Nursing, no certified Infection Control Preventionist, and an administrator who held only a temporary license and had been in the role since August 2023. The inspection, conducted August 1, 2024, found that the holes in leadership had produced holes in care across the building's 64 residents.
The administrator-in-training also confirmed she had no record of abuse training for V17 at the facility. Agency staff, she explained, were given a binder at the nurses' station to read and sign. The abuse policy was not in the binder.
This was not the facility's first abuse problem. The administrator acknowledged two prior abuse citations, one in April 2024 and one in June 2024. Both involved sexual abuse. Both involved the same perpetrator. "We talk about Abuse in QAA monthly," she said, "and we started talking about it more in April with the first Abuse citation we received."
Talking about it more had not stopped a third incident from occurring by July.
A second resident, R47, described her own experience with a licensed practical nurse identified as V7. R47 told inspectors the nurse had made her feel afraid to speak to her. She said she was moved to a different room afterward, and that the former Director of Nursing "acted like it was her fault." As of the inspection, V7 still worked in the building and had spoken to R47 since the incident. They did not get along, R47 said.
The administrator-in-training told inspectors she had been aware of R47's verbal abuse allegation but had deferred to the Director of Nursing to handle it. She confirmed she had no abuse documentation, no investigation records, and no documented measures to prevent R47 from being abused, intimidated, or scared again.
On July 29, 2024, a registered nurse identified as V14 arrived for her first day working at the facility as an agency nurse. She had not been oriented to the building. She was working upstairs. The nurse who was supposed to train her was downstairs on a different hall, simultaneously training two other staff members.
That morning, V14 did not administer a scheduled blood glucose check and insulin dose to a diabetic resident, identified as R5, before breakfast. When R5's blood sugar came back elevated and outside of insulin parameters, V14 went to the nurses' station to call the resident's nurse practitioner. She could not find a phone number for the provider. She searched for ten minutes.
Then she picked up the phone and called the administrator-in-training. "Today is my first day," V14 said. "I don't know the flow or where things are. I am not sure how to dial out on the telephone. I don't even know what the Administrator looks like. I don't think the facility has a DON."
The administrator-in-training came to the nurses' station and also searched for several minutes before locating the nurse practitioner's number.
A different resident, R52, had been missing her Sinemet, a medication used to treat Parkinson's disease, for five consecutive days, from July 25 through July 30. No new physician order had been written. No medication error report had been filed, for those missed doses or for a similar lapse in June. The interim Director of Nursing said she had been unaware the medication was not being given and that the facility had allowed the order to expire without notifying the neurologist. "I am unsure what the nurses are supposed to do when a medication has been missed or a medication error has been made," she said. "I would have to look at the Medication Policy to see what the nurses should have done."
The family of another long-term resident, R12, had been trying to get answers since spring. R12's family member told inspectors that other families had alerted them in spring 2024 that R12 wasn't acting like herself. R12 said she wasn't getting her medications. When the family member raised this with the administrator-in-training, the response was: "I don't know what the nurses do." That was all the resolution they received.
Two residents, R15 and R60, had physician orders for their code status that did not match their POLST forms, the documents that direct emergency responders on whether to attempt resuscitation. The administrator-in-training confirmed the mismatch and said she had not conducted an audit to check whether orders and POLST forms aligned across the building. "Social Services is responsible for ensuring the resident's physician order for advance directives match the resident's current POLST form," she said. "We currently don't have a Social Service Director, so I have been trying to help with the advance directives."
She had not done the audit.
The facility also could not document that residents or their representatives had been given bed hold policies when sent to the hospital, a basic notification that tells families whether their loved one's room will be held while they are away. The administrator-in-training said she was not sure nursing staff even knew to provide the information.
The infection control function had been folded into the interim Director of Nursing's responsibilities, a combination the administrator-in-training acknowledged was not how it was supposed to work. "I know they are supposed to be separate roles," she said. The facility's infection control preventionist certificate could not be located. The interim Director of Nursing had also missed the July quality assurance meeting. The Medical Director had not attended the November meeting. The administrator-in-training herself had not been present in March.
The quality assurance process the administrator's own job description required her to maintain, the one meant to catch exactly these kinds of cascading failures before they reached residents, had been running without its key participants for months.
R315 was still in the building when inspectors left. The resident who said she was scared had been there for three days since the substantiated abuse, and the administrator-in-training still had not spoken to her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Loft Rehabilitation & Nursing from 2024-08-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
LOFT REHABILITATION & NURSING in EUREKA, IL was cited for violations during a health inspection on August 1, 2024.
The administrator-in-training acknowledged this herself.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.