A list of the most recent deficiencies for Loft Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2024-01-08 | 2024-01-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-08 | 2024-01-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-08 | 2024-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-28 | 2023-08-18 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-31 | 2023-07-05 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-26 | 2023-06-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-26 | 2023-06-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-26 | 2023-06-13 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-31 | 2023-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-06-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-12 | 2022-12-16 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-07-16 | 2022-08-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-16 | 2022-08-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-07-16 | 2022-08-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-14 | 2022-05-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-14 | 2022-05-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-14 | 2022-05-13 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-04-14 | 2022-05-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-14 | 2022-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-14 | 2022-05-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-14 | 2022-05-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-14 | 2022-05-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-05-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-04-14 | 2022-05-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-14 | 2022-05-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-14 | 2022-05-06 | N |
| Post nurse staffing information every day. | Health | 2022-04-14 | 2022-05-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-04-14 | 2022-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-14 | 2022-05-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-04-14 | 2022-05-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-04-11 | 2022-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-05-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-11 | 2022-05-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-11 | 2022-04-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-11 | 2022-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-11 | 2022-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-11 | 2022-04-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-14 | 2022-04-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-14 | 2022-04-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-14 | 2022-04-14 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-14 | 2022-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-20 | 2022-03-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-10 | 2022-03-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-10 | 2022-03-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-10 | 2022-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-10 | 2022-03-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-16 | 2022-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-16 | 2022-02-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-06 | 2022-01-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-06 | 2022-01-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-01-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-01-23 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-12-21 | 2022-01-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-21 | 2022-01-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-21 | 2022-01-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-21 | 2022-01-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-24 | 2021-12-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-24 | 2021-12-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-11-24 | 2021-12-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-08 | 2021-12-10 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-08 | 2021-12-10 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-11-12 | 2021-12-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-08 | 2021-12-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-29 | 2021-10-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-21 | 2021-10-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-21 | 2021-10-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-21 | 2021-10-19 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-21 | 2021-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-21 | 2021-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-09 | 2021-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-14 | 2021-05-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-18 | 2021-04-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-18 | 2021-03-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-18 | 2021-03-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-18 | 2021-03-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-02-18 | 2021-03-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-18 | 2021-03-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-18 | 2021-03-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-18 | 2021-03-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-02-18 | 2021-03-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-02-18 | 2021-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-18 | 2021-03-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Develop a communication plan. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Establish methods for sharing information. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-02-18 | 2021-03-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-02-18 | 2021-03-08 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-02-18 | 2021-03-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-02-18 | 2021-03-01 | N |
| Respond appropriately to all alleged violations. | Health | 2021-02-18 | 2021-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2021-02-18 | 2021-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-18 | 2021-03-01 | N |
