A list of the most recent deficiencies for Loft Rehab of Decatur. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-01-30 | 2024-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-30 | 2024-02-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-21 | 2023-09-06 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-28 | 2023-07-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-28 | 2023-07-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-28 | 2023-07-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-28 | 2023-07-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-28 | 2023-07-10 | 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 | 2023-06-28 | 2023-07-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-28 | 2023-07-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-28 | 2023-07-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-28 | 2023-07-10 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2023-06-28 | 2023-07-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-28 | 2023-07-10 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-06-28 | 2023-07-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-14 | 2023-07-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-14 | 2023-07-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-14 | 2023-07-05 | 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 | 2023-06-14 | 2023-07-05 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-06-14 | 2023-07-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-14 | 2023-07-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-14 | 2023-07-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-14 | 2023-07-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-14 | 2023-07-05 | 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 | 2023-06-14 | 2023-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-14 | 2023-07-05 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-31 | 2023-06-21 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-31 | 2023-06-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-31 | 2023-06-21 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-05-10 | 2023-05-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-10 | 2023-05-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-05-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-10 | 2023-05-25 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-10 | 2023-05-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-28 | 2023-05-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-04-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-28 | 2023-04-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-09 | 2023-02-23 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-09 | 2023-02-23 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-09 | 2023-02-23 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-09 | 2023-02-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-17 | 2023-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-17 | 2023-02-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-01 | 2022-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-12-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-11 | 2022-12-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-01 | 2022-12-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-11 | 2022-11-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-06 | 2022-11-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-06 | 2022-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-06 | 2022-10-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-06 | 2022-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-10-17 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-06 | 2022-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-06 | 2022-10-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-06 | 2022-10-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-14 | 2022-10-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-14 | 2022-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-14 | 2022-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-14 | 2022-10-14 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-09-14 | 2022-10-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-14 | 2022-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-14 | 2022-10-14 | 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 | 2022-09-14 | 2022-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-14 | 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 | 2022-09-14 | 2022-10-14 | 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 | 2022-09-14 | 2022-10-14 | N |
| Provide or obtain dental services for each resident. | Health | 2022-09-14 | 2022-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-14 | 2022-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-25 | 2022-06-18 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-25 | 2022-06-18 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-18 | 2022-04-30 | Y |
| Keep all essential equipment working safely. | Health | 2022-04-18 | 2022-04-30 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-18 | 2022-04-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-09 | 2022-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-01 | 2022-04-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-01 | 2022-04-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-09 | 2022-03-30 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-01 | 2022-03-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-01 | 2022-03-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-01 | 2022-03-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-01 | 2022-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-03-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-01 | 2022-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-03-30 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-01 | 2022-03-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-13 | 2022-03-30 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-11-04 | 2021-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-28 | 2021-11-25 | 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 | 2021-10-28 | 2021-11-25 | 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 | 2021-10-28 | 2021-11-25 | 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 | 2021-10-28 | 2021-11-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-28 | 2021-11-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-10-28 | 2021-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-28 | 2021-11-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-28 | 2021-11-25 | 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 | 2021-10-28 | 2021-11-25 | 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 | 2021-10-28 | 2021-11-25 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-28 | 2021-11-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-28 | 2021-11-25 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-10-28 | 2021-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-11-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-28 | 2021-11-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-28 | 2021-11-25 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-28 | 2021-11-25 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-10-28 | 2021-11-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-04 | 2021-11-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-10-14 | 2021-11-01 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-14 | 2021-11-01 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-10-14 | 2021-11-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-01 | 2021-09-27 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-28 | 2021-05-12 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-04-28 | 2021-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-28 | 2021-05-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-12 | Y |
| 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 | 2021-04-28 | 2021-05-12 | Y |
