Loft Rehabilitation & Nursing
LOFT REHABILITATION & NURSING in EUREKA, IL — inspection on August 1, 2024.
Found 19 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
to participate in experimental research, and to formulate an advance directive.
interview and record review, the facility failed to maintain accurate Advanced Directive information
Directives in the sample of 39.
Findings include:
- R15's Order Summary Report, dated [DATE], documents R15 was admitted to the facility on
[DATE] with the following, but not limited to, diagnoses: Frontal Lobe and Executive Function Deficit Following Cerebral Infarction, Vascular Dementia, and Cardiac Murmur.
This same report documents the following Physician order, Order date [DATE]: Full Code.
R15's Illinois Department of Public Health Uniform Practitioner Order for Life Sustaining Treatment (POLST) Form, dated [DATE], documents A. No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation. B.
Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management.
Allow natural death.
- R60's Order Summary Report, dated [DATE], documents R60 was admitted to the facility on
[DATE] with the following, but not limited to, diagnoses: Malignant Neoplasm of Prostate, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Malignant Neoplasm of Bladder.
This same report documents the following Physician order, Order date [DATE]: Full Code.
R60's Illinois Department of Public Health POLST Form, dated [DATE], documents A. No CPR. Do Not Attempt Resuscitation. B.
Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management.
Allow natural death.
On [DATE] at 2:15 PM V1/Administrator in Training verified R15 and R60's Physician order and POLST form did not match. V1 stated, Social Services is responsible for ensuring the resident's physician order for advance directives match the resident's current POLST form. We (the facility) currently don't have a Social Service Director, so I have been trying to help with the advance directives. I have not done an audit to ensure the order and POLST form match to ensure the staff know the appropriate code status for the residents.
The facility's Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], documents Policy: It is the policy of this facility to support and facilitative a resident's right to request, refuse and or/discontinue medical or surgical treatment and to formulate an advance directive.
Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health are when the individual is incapacitated.
Policy Explanation and Compliance Guidelines: 1.
The facility will include in the standing orders: Advance directive as indicated by the resident and/or resident representative. 5.
Upon admission, should the resident/resident representative execute a new advance directive; or, if a resident or resident representative changes the advance directive c.
The advance directive will be added to Physician Orders. e.
The original of the POLST will be scanned into resident record after signed by the physician.
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Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530
screaming in (R315's) face that the jail was right down the street and that's where she (R315) is
crying. (V10) and I walked up to (R315) to comfort her. (V10) told (V17) to stop and (V17) walked way.
Licensed Practical Nurse) to call (V1/Administrator in Training) so I did.
On 7/31/24 at 2:45 PM V1/Administrator in Training stated, (V8/CNA) and (V10/CNA) called and reported to me alleged verbal and mental abuse from (V17/Agency CNA) to (R315). (V8) and (V10) both stated they witnessed the abuse. (V17) will not be allowed to come back to work here. I have not spoken with (R315) 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. V1/Administrator in Training also verified that she had no record of Abuse Training for (V17) from the facility. V1 stated she has a binder at the nurse's desk that the agency staff reads and signs off on but verified that the abuse policy was not in the binder.
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resident verbal abuse for the past year.
allegation, but anything medication wise, I let to the DON (Director of Nursing) handle. I am aware it
abuse documentation or any reported incidents to document any of R47's verbal abuse and intimidation allegations.
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Investigation of Alleged Abuse, Neglect and Exploitation- When suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted.
Once the resident is cared for and initial reporting has occurred, an investigation should be conducted.
Components of an investigation may include.
Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident.
Interview all witnesses separately.
Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area.
Obtain witness statements, according to appropriate polices.
Document the entire investigation chronologically.
On 07/30/24 at 10:15 AM, R47 was lying in bed in her room. R47 stated I used to love it here but then back in March when I was on hospice and needed morphine. I put my call light on and waited for an hour and a half.
After that I got into my wheelchair and went to find my nurse, (V7, Licensed Practical Nurse).
Once I found (V7), she told me I do not appreciate you coming to find me and approaching me about your medicine. I will come back to your room and give you your medicine.
After getting my medication, (V7) left the room and then came back in and said, 'You are nothing but a pain seeker and pill popper.' At this time R47 was crying and said she has a lot of medical issues and is in pain all the time. R47 stated she doesn't deserve to be treated like this. R47 stated when she reported this to the V23 (Former Director of Nursing) she was moved to another hallway and not given any notice. R47 stated she was told by V23 that this was the solution. R47 stated that a few weeks ago she did have V7 as her nurse and she did not receive her medicine. R47 stated when she asked V7 for her medication V7 stated I don't know, your nurse has them. R47 stated later that day V23 approached her and stated, Never speak to (V7) again. Do not talk to her again. R47 stated she used to love it at the facility, but now all she wants to do is stay in her room and feels very lonely. R47 stated The facility only cares about the staff and does not protect the residents.
R47's current electronic medical record does not document any allegations or investigation of resident to staff verbal abuse for the past year.
On 7/30/2024 at 11:52 AM, V1 (Administrator in training) stated I was aware of the verbal abuse allegation, but anything medication wise, I let to the DON (Director of Nursing) handle. I am aware it was a verbal abuse allegation. (V23) was handling it. At this time V1 confirmed she does not have any abuse documentation, investigation or reported incidents to document any of R47's verbal abuse and intimidation allegations. V1 also confirmed she also does not have any documented measures to prevent R47 from being abused, feeling intimidated or feeling scared after the alleged incident.
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ombudsman, before transfer or discharge, including appeal rights.
minimal harm Based on interview and record review the facility the failed to notify the facility Ombudsman monthly of resident transfers to the hospital and failed to provide the resident and resident representative
residing in the facility.
Findings Include: 1.) R3's medical record documents that R3 was transferred to a local hospital on 7/11/24. No evidence of a facility notification of a transfer/discharge was present on R3's chart. 2.) R18's medical record documents that R18 was transferred to a local hospital on 6/22/24. No evidence of a facility notification of a transfer/discharge was present on R18's chart. 3.) R27's medical record documents that R27 was transferred to a local hospital on 1/28/24. No evidence of a facility notification of a transfer/discharge was present on R27's chart. 4.) R5's medical record documents that R5 was transferred to a local hospital on 3/8/2024. No evidence of a facility notification of a transfer/discharge was present on R5's chart. 5.) R48's Progress Notes, dated 7/18/2024, documents the following: R48 was admitted to the local hospital after a functional decline. No evidence of a facility notification of a transfer/discharge was present in R48's chart. 6.) R52's medical record documents that R52 was transferred to a local hospital on 4/22/24. No evidence of a facility notification of a transfer/discharge was present on R52's chart. 7.) R315's medical record documents that R315 was transferred to a local hospital on 7/24/24, 7/28/24, and 7/29/24. No evidence of a facility notification of a transfer/discharge was present on R315's chart.
On 7/31/24 at 10:30 A.M., V1/Administrator in Training verified that the facility was unable to provide documentation that residents or their representative are provided with a written notice of transfer. At that time, V1/Administrator in Training also confirmed that she had not sent notification to the local Ombudsman of monthly facility transfers/discharges.
The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/29/24 and signed by V1/Administrator in Training documents 64 residents currently reside within the facility.
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nursing staff are even aware to give residents a bed hold policy when they discharge to the hospital.
minimal harm The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/29/24 and signed by V1/Administrator in Training
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reviewed, and revised by a team of health professionals.
of 24 residents (R17) in a sample of 39 reviewed for care plans.
Findings Include: The facility policy, named Care Plan Revision Upon Status Change, revised 1/25/2024, documents the following, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.
Policy Explanation and Compliance Guidelines: 1.) A comprehensive care plan will be reviewed, and revised as necessary, when the resident experiences a status change.) The care plan will be updated with the new or modified interventions.
R17's Face Sheet, dated 7/7/2024, documents: Special Instructions: UNDER NO CIRCUMSTANCES IS V21- R17's Friend, ALLOWED TO TAKE R17 OFF THE PROPERTY. V21 is allowed to visit; V21 is allowed to go outside with resident as long as they DO NOT leave the property. V21 is NOT allowed to bring in outside food and beverages.
The facility Resident/Family Complaint, dated 7/8/2024, documents the following: R17 left the building with V21/R17's Friend and did not return to the building until around 3:00 PM that day.
When V4/Activity Director brought R17's absence up to the attention of V12/LPN (Licensed Practical Nurse) she did not seem to have a concern about R17 or that V22/R17's Family Member, was very worried about R17. (R17) left the facility with V21/Friend at 8:00 AM and R17 had not returned in four hours.
On 7/29/2024 at 2:33PM V2/Interim DON (Director of Nurses) stated, R17's care plan is not updated to show the special instructions that R17 is not to leave the facility with R17's significant other (V21).
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sample of 39.
Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 12/5/23, documents Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care.
Assisting with coordinating other care and physician services.
This same policy documents A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
R12's current Care Plan, dated 6/1/24, documents (R12) has an ADL self-care performance deficit related to dementia, spinal stenosis, depression, altered mental status.
Interventions/Tasks: Bathing/Showering; Requires staff supervision with showering.
Prefers a bath at least one time weekly.
This same care plan documents R12 is cognitively intact has diagnoses of Sciatica, Pain in Joints, Difficulty in Walking and Lack of Coordination.
On 7/29/24 at 12:18 PM, V20 (R12's Family Member) stated She (R12) isn't getting showers.
She's went weeks without a shower.
R12's current Physician Orders, dated 7/30/24, documents R12 has a physician order to Start antibacterial soap daily to bathe/shower 7 days prior to surgery (start July 29, 2024) every day and night shift prior to surgery until 8/5/2024.
On 7/30/24 at 9:25 AM R12 was sitting in her room in a recliner chair. R12 stated I am not happy about much here anymore.
Residents suffer cause we can't get the help we need due to staff always being busy. I need a bath everyday this week. I am not getting them for some reason. I was supposed to have one yesterday and did not get it.
On 7/31/24 at 10:00 AM V1 (Administrator in Training) stated the staff should document in the computer when they give residents baths or showers.
R12's electronic shower/bath task dated, July 2024, documents R12's last shower or bath was given on 7/23/24.
On 8/1/24 at 9:33 AM, V29 (Certified Nursing Assistant) stated staff usually do a shower sheet for baths and showers and they are documented in the computer.
On 8/1/24 at 1:30 PM V11 (Vice President of Clinical Operations) provided R12's paper shower sheet documentation for July and confirmed the two most recent showers that R12 received took place on 7/23/24 and 7/31/24 (missing two scheduled showers on 7/29 and 7/30/24.)
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prevent accidents.
leave the building unsupervised for one (R17) of three residents reviewed for Safety in a sample of 39.
Findings Include: The facility policy, Accidents and Supervision, dated 1/5/2023, documents, The resident environment will remain as free of accident hazards as is possible.
Each resident will receive adequate supervision and the facility will provide the adequate supervision.
R17's Diagnosis Information documents the following diagnosis: Cerebral Infarction Frontal Lobe with Executive Function deficit, Alcohol Induced Dementia, Alcohol Dependence, Schizoaffective Disorder, Bipolar Type, Schizophrenia, Major Depressive Disorder, moderate, Anxiety Disorder, and Cognitive Social Deficit.
On 7/29/2024 at 10:36 AM V1/Administrator in Training, stated, R17 left the faciity on 7/6/2024 with V21 (R17's Friend) to go out for lunch. V22 (R17's Family Member), informed staff later that day, that R17 should never leave the facility with V21.
They both are alcoholics, and this is why I do not want her going out with V21.
When they are together, they drink a lot and they both get out of control.
The previous facility should have sent you the paperwork and informed you of this. I am R17's HCPOA (Health Care Power of Attorney), and I do not want R17 leaving the facility with V21.
On 7/30/2024 at 8:45 AM V4/Activity Director stated, I called V22 (R17's Family Member), because I was concerned. V21 (R17's Friend) had taken R17 out in the morning and R17 had been gone more than four hours. I was getting worried. We were not informed that R17 was not to go out of this facility with V21.
On 7/29/2024 at 3:35 PM V12/LPN (Licensed Practical Nurses), stated, I allowed R17 to leave the facility with V21 (V17's Friend). I had no idea that R17 was not to leave the facility with V21. No one had told me this or I must have missed this in report, and it was not flagged anywhere in the chart.
R17 signed herself out. R17 was alert and oriented when R17 left. R17 was gone at least six hours and came back in good spirits, did not smell like alcohol, and did not act like she was drinking.
The local police were called by V22 (R17's Family Member). V22 told the police that R17 was missing, R17 was not missing. At the time that R17 left I did not realize that R17 was a recovering alcoholic. I guess I did not pay attention to what was in her chart.
The local police were called, and they wanted me to call them when R17 came back to the facility. I called the police when R17 came back to the facility.
The police did an assessment on R17 to ensure that R17 was not under the influence of alcohol and R17 was not. R17 told me that she drank a glass of wine with dinner.
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catheter care, and appropriate care to prevent urinary tract infections.
catheter tubing was off the floor and an indwelling catheter urinary drainage bag was covered for one
Findings include: The facility's Catheter Care Policy, dated 1/24/23, documents Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.
Policy Explanation: 2.
Privacy bags will be available and catheter drainage bags will be covered at all times while in use.
R15's Order Summary, dated 7/30/24, documents the following physician order: Maintain indwelling catheter with 16 french 20 cubic centimeter balloon.
R15's current Care Plan, dated 5/1/24, documents I have an Indwelling (Urinary) Catheter related to obstructive uropathy and urinary strictures.
On 7/29/24 at 9:51 AM R15 was sitting in her wheelchair in the middle of the memory care unit hallway. R15's indwelling urinary catheter drainage bag was attached underneath her wheelchair uncovered with the indwelling urinary catheter tubing lying on the floor.
On 7/30/24 at 1:24 PM R15 was sitting in her wheelchair in her room watching television. R15's indwelling urinary catheter drainage bag was attached underneath her wheelchair uncovered and visible from the hallway. R15's indwelling urinary catheter tubing was lying on the floor underneath her wheelchair. V9/Licensed Practical Nurse verified R15's indwelling urinary catheter drainage bag was uncovered, and her indwelling urinary catheter tubing was lying underneath R15's wheelchair on the floor. V9 stated, (R15's) urinary catheter bag should be covered with a dignity bag and the tubing should not be dragging on the floor. I am not sure why it is.
On 7/30/24 at 2:51 PM V2/Regional Nurse Consultant stated, Staff should always ensure resident's urinary catheter drainage bags are placed in a privacy bag and the catheter tubing should never be dragging on the floor.
The staff know that.
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nurses on a full time basis.
Coverage seven days a week.
This has the potential to affect all 64 residents living in the facility.
Findings
The Facility's Nursing Schedule for the month of July states there is no Registered Nurse coverage for the following days: 7/06/24; 7/07/24; 7/13/24; 7/20/24; 7/21/24; 7/26/24; 7/27/24; 7/28/24.
The document, (Facility) Daily Posting of Nurse and Certified Nurse Assistant, was also checked for Registered Nurse (RN) coverage.
Several days (which are the same dates of no RN coverage) were not posted: 7/06/24; 7/07/24; 7/13/24; 7/20/24; 7/21/24; 7/26/24; 7/27/24; 7/28/24.
This was confirmed by V1, Administrator in Training, on 7/31/24 at 2:15 PM.
On 8/01/24 at 10:25 AM, V1, Administrator in Training, stated, We have given you what you requested, including the Agency Nurses that worked. It has been difficult to have Registered Nurse coverage on weekends.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24, signed by V1, Administrator in Training, documents 64 residents currently reside within the facility.
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minimal harm Nurse and Certified Nurse Assistant posted each day.
This has the potential to affect all 64 residents living in the facility.
Findings
The document, (Facility) Daily Posting of Nurse and Certified Nurse Assistant, could not be provided for the following days: 7/02/24; 7/04/24; 7/06/24; 7/07/24; 7/13/24; 7/14/24; 7/20/24; 7/21/24; 7/25/24; 7/26/24; 7/27/24; 7/28/24; 7/29/24.
On 7/29,24 at 9:15 AM, the Daily Posting of Nurse and Certified Nurse Assistant posting which was located on the Receptionist's desk in the Faciity's Lobby, was dated, 7/25/24.
On 7/31/24 at 2:15 PM, V1, Administrator in Training, confirmed these postings were not available, stating, No, the Daily Posting of Nurse and Certified Nurse Assistant were not always posted.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24, signed by V1, Administrator in Training, documents 64 residents currently reside within the facility.
medication error rate 6.9% for one of five residents (R5) reviewed for medication administration in the
Findings include: R5's current Medication Administration Record (MAR), dated 7/1/24-7/31/24, documents R5 has an order for blood glucose monitoring followed by a sliding scale Insulin Aspart Injection Solution 100 units/milliliter.
Inject as per sliding scale: if 110 - 140 = 5; 141 - 169 = 6; 170 - 199 = 7; 200 - 229 = 8; 230 - 259 = 9; 260 - 289 = 10; 290 - 319 = 11; 320 - 349 = 12; 350 - 399 = 13 call provider for above 400, subcutaneously before meals related to Type Two Diabetes Mellitus This (MAR) documents administration times are 7:30 AM, 11:30 AM and 5:30 PM, before meals.
R5's current Medication Administration Record (MAR), dated 7/1/24-7/31/24, documents, R5 has an order for Metformin Oral Tablet (medication to lower blood sugar) 500 milligrams.
Give 500 mg by mouth one time a day related to Type two Diabetes Mellitus.
Scheduled time is 8:00 AM.
On 7/29/24, at 10:30 AM, V14 (Registered Nurse/RN) checked R5's blood glucose level and then administered R5's Metformin by mouth in a spoon with a sip of water.
On 7/29/24, at 10:40 AM, V14 verified that R5's blood sugar monitoring with sliding scale insulin should have been given before R5 ate breakfast and that R5's Metformin should have been given at 8:00 AM. V14 stated I am new here and this is my first day, I am just learning the floor.
The Facility Medication Administration Policy Dated 1/4/2023 documents Medications administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
This policy also documents for medication administration Administer within 60 minutes prior or after scheduled time unless otherwise ordered by physician.
The facility must ensure that it is free of medication error rates of five percent or greater as well as significant medication error events.
The Facility Medication Error Policy, dated 9/28/2023, documents It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents care and services safely in an environment free of significant medication errors.
Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principals which apply to professionals providing services.
This policy also documents The facility must ensure that it is free of medication error rates of five percent or greater as well as significant medication error events.
The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a.
Medication administered not in accordance with the prescriber's order.
Examples include but not limited to incorrect dose, route of administration, dosage form, time of administration, medication omission, and incorrect medication.
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balance, increased tremors, and sleepiness. (V15/R52's Neurology Nurse Practitioner) wrote a new
weeks.
Before the four weeks were up the facility was supposed to update us with how (R52) was
did not receive an update and did not know the facility allowed the Sinemet order to expire. (The facility) did not call our office until [DATE] letting us know they had allowed the Sinemet order to expire and forgot to call and give us an update. (The facility) reported (R52) had not received the Sinemet since [DATE]. (The facility) reported at that time they noticed a difference when (R52) was on the Sinemet and that she was more awake, and alert and her balance was much better. (V16) wrote a new order on [DATE] to start the Sinemet titration over again and for the facility to call our office to update how (R52) is tolerating the mediation. It was instructed to call us before week four was up and to not allow the medication order to expire. (The facility) has not called us to give us an update and I was unaware (R52) has not received her Sinemet since [DATE]. (R52) could experience increased fatigue, unsteady gait, and tremors for stopping the medication once again.
On [DATE] at 2:30 PM, V2 (Regional Nurse Consultant/Interim Director of Nursing) stated she was unaware that R52 has not been receiving her Sinemet or that the facility did not call to give Neurology an update and allowed the medication order to expire and that this is the second time it has happened.
V2 stated, I am unsure what the nurses are supposed to do when a medication has been missed or a medication error has been made.
They should have caught it before hand and called the ordering physician. I would have to look at the Medication Policy to see what the nurses should have done. No medication error report was filled out for the missed doses of Sinemet in June or [DATE].
On [DATE] at 10:30 AM, V28/R52's Primary Physician stated the facility did not notify him of needing an updated order for R52's Sinemet in June or [DATE] or that R52 had missed doses of her Sinemet.
V28 stated, (R52) could experience increased tremors and excessive tiredness when stopping Sinemet. It's not good (R52) missed her doses. It doesn't cause a long-term effect, but It can cause a short-term effect for (R52).
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Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530
container did not have a label describing its contents and the lid was not tight fitting failing to seal
to have been in the refrigerator for some time.
These contained lasagna; beef stew with potatoes on
containers.
The refrigerator also held two custard pies, loosely covered with parchment paper, dated 7/22/24 to be used 7/24/24; an eight fluid ounce container of a Thickened Dairy Beverage had an expiration date of 4/26/24; an opened 10 ounce jar of medium chunky salsa, 25 percent full, had a crusty substance surrounding the lid, without an open date or label; a half full plastic cup containing an unknown substance did not have a label or date; a five pound 50 percent full container of Parmesan cheese did not have a label or open date. V5 acknowledged these deficiencies.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24, signed by V1, Administrator in Training, documents 64 residents currently reside within the facility.
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have to look at the Medication Policy to see what the nurses should have done. No medication error
On 7/30/24 at 1:30 P.M., V1(Administrator in Training) verified that the facility was unable to provide
residents are sent out to the hospital. V1 stated, We (the facility) currently do not have a Social Service Director and only have an Interim-Director of Nursing, so I am not sure the nursing staff are even aware to give a bed hold policy to resident's when they discharge to the hospital.
On 7/30/24 at 2:15 PM V1 (Administrator in Training) verified R15 and R60's Physician order and POLST (Physician Order for Life Sustaining Treatment) form do not match. V1 stated, Social Services is responsible for ensuring the resident's physician order for advance directives match the resident's current POLST form. We (the facility) currently don't have a Social Service Director, so I have been trying to help with the advance directives. I have not done an audit to ensure the order and POLST form match to ensure the staff know the appropriate code status for the residents.
On 7/31/2024 at 11:35 PM V1 (Administrator in Training) confirmed that V2 is the Interim Director of Nursing and is filling duties for the facility's Infection Control Preventionist. V1 stated, I was not able to locate the Infection Preventionist certificate.
On 7/31/24, at 11:00 AM, V1 (Administrator in Training) stated she has her temporary Nursing Home Administrator license and started working as the facility's administrator on 8/13/2023.
On 8/1/24 at 11:35 AM, V1 confirmed the facility has several agency nurse and nursing assistants. V1 stated The nurses on the floor are responsible for reconciling physician orders and making sure they are implementing those. (V2, Interim Director of Nursing) has been helping out as well.
When Nurses or CNA's (Certified Nursing Assistants) are agency they are orientated when they come in for their first shift. I orientate now, or the CNA or Nurse that they are working with will. So when a new agency nurse comes here there is a binder they are to look at and the nurse working with them should train them.
Monday (7/29/24) we had two agency nurses (V14 Registered Nurse and V24 Licensed Practical Nurse) and so (V12 Licensed Practical Nurse) was our nurse who should be making sure (V14) was orientated since it was her first day. (V12) was also training (V35, Licensed Practical Nurse) and they were downstairs working on the 600 hall. (V14) was working upstairs. V1 confirmed she was made aware of more abuse concerns this week. V1 stated We have had the two prior abuse citations recently.
One was in April and another in June.
Both were sexual abuse and the same perpetrator. We talk about Abuse in QAA (Quality Assessment and Assurance) monthly and we started talking about it more in April with the first Abuse citation we received. We don't have a designated Infection Control Preventionist (ICP), those duties have been completed by the DON. I know they are supposed to be separate roles. We didn't have either the ICP or the DON at our July meeting. In March I think I just wasn't able to be there (QAA meeting) that day and in November we didn't have the Medical Director present (at the QAA meeting).
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 documents 64 residents currently reside within the facility.
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quarterly
the facility's scheduled Quality Assurance meetings.
This failure has the potential to affect all 64
Findings include: The facility's Facility Assessment, dated 7/24/24, documents the assessment was reviewed on 7/24/24 with the QAA/QAPI (Quality Assessment and Assurance/Quality Assurance and Performance Improvement) committee.
The facility's QAPI plan, dated 7/3/24, documents The QAA committee will review data from areas the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization.
Members of the QAA committee may be added according to the perceived needs of the community, however will have as key members the following positions: Medical Director, Administrator, Director of Nursing, Regional Nurse Consultant, Regional Operations Consultant, Infection Preventionist.
The facility's (undated) Quality Assurance Committee list, provided by V1 (Administrator in Training), does not include an Infection Control Preventionist (ICP).
The facility's QA (Quality Assurance) sign in sheet, dated 7/25/24, documents the Interim Director of Nursing (DON, V2) was not in attendance to the July 2024 meeting.
The facility's QA sign in sheet, dated 3/13/24, documents the only members in attendance to the March 2024 QA meeting were V23 (Former Director of Nursing), V28 (Medical Director) and V34 (former Dietary Manager).
The facility's QA sign in sheet, dated 11/16/23, documents the facility's Medical Director (V28) was not in attendance.
On 8/1/24 at 11:35 AM, V1 (Administrator in Training) confirmed that all required members have attended the quarterly QAA meetings. V1 stated We don't have designated ICP, those duties have been completed by the DON. I know they are supposed to be separate roles. We didn't have either the ICP or the DON at our July meeting. In March I think I just wasn't able to be there that day and in November we didn't have the Medical Director present.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 documents 64 residents currently reside within the facility.
145431 08/01/2024
Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530
program in the nursing home.
Preventionist and failed to obtain the certificate to show the completion of the training.
This failure
Findings Include: The Facility Assessment, dated July 24, 2024, documents the following: Training requirements. A facility must develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment.
On 7/30/2024 at 2:23 PM V2/Interim DON (Director of Nurses) stated, I will try to find the certificate to show that I have completed the appropriate infection control training. I didn't see it after I was done with the training.
Yes, I just completed most of the training late in the evening yesterday, 7/29/2024 at 6:10 PM. I stayed up last night to try and get it all done.
All the training to become an Infection Preventionist was not done prior to your entrance on 7/29/24.
On 7/31/2024 at 11:35 PM V1/Administrator in Training stated, I was not able to locate the Infection Preventionist certificate.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 7/29/24 and signed by V1/Administrator in Training, documents 64 residents currently reside within the facility.
145431 08/01/2024
Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530
F-F882.
These failures have the potential to affect all 64 residents residing at the facility.
Findings include:
The facility's Administrator job description, dated June 2021, documents Major duties and responsibilities: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations.
Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators.
Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility.
Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revision related to the facility's outcomes, regulatory compliance and/or customer satisfaction.
Ensures implantation of any and all new policies, procedures, guidance and regulations as directed by the (facility) corporate team.
Ensures delivery of excellent customer service and compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially.
Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etcetera, are reported to the correct entity within the stated regulatory requirement.
Promotes safe work practices, safety rules, and accident prevention procedures to prevent employee injury and illness.
The facility's Social Services Designee job description, dated June 2021, documents The Social Services Designee will assist the Administrator in the planning, developing, organizing, implementing, evaluating, and directing of social services programs of this facility.
The social service designee will meet with administration, medical and nursing staff, and other related departments in planning social services, as directed.
The social services designee will assist the administrator in ensuring that staff members are knowledgeable about resident's rights and encourage staff to maintain and enhance each resident's dignity in recognition of each resident's individuality.
The social services designee will engage in advance care planning for assigned residents upon admission, and make sure that any advanced directives are reviewed with the resident/resident representative on a regular basis.
The social worker will ensure that staff members are made aware of the resident's code status and end of life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications.
The social services designee will advocate for residents and assist them in assertion of their rights within the facility.
The social services designees will assist with investigations of abuse allegations.
145431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 145431 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Loft Rehabilitation & Nursing 700 North Main Street Eureka, IL 61530
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.