Loft Rehab of Rock Springs, the

Inspectors wroteBased on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This failure has the potential to affect all 100 residents residing in the facility. Findings Include:Facility Nursing Staff Schedules reviewed from 4/4/26 through 5/4/26 documented seven days (4/5, 4/18, 4/19, 4/22, 4/23, 4/24, and 5/2) the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day. On 5/4/26 at 2:00 PM, V2 Director of Nurses (DON) stated she was on vacation 4/22/26 through 4/27/26, her normal scheduled workdays/hours are Monday through Friday 9:30 AM - 5:30 PM, and she hasn't covered any weekend RN shift in the last month. V2 DON confirmed V2 DON did not have eight hours of RN coverage on any weekend days that were vacant of RN staff in the last month. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 100 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to prevent direct biological cross-contamination of food service equipment, failed to maintain a sanitary can opener, and failed to maintain sanitary floor and food preparation surfaces. These failures have the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a water management plan that clearly defined the ranges for control measures and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 100 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ a full-time Infection Preventionist as specified in the Facility Assessment. This failure has the potential to affect all 100 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of food preparation surfaces. This failure has the potential to affect all 100 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms, hallways, and dining area were clean and in good repair for three of three residents (R18, R79, and R82) reviewed for homelike environment in the sample list of 42.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were educated on and offered pneumococcal immunizations in accordance with current Centers for Disease Control (CDC) recommendations. This failure affects three (R7, R8, and R9) of five residents reviewed for immunizations on the sample list of 42.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete R5's comprehensive assessment. This failure affects one (R5) of two residents reviewed for accuracy of assessments on the sample list of 42.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinence care for one resident (R18) of 32 reviewed for Activities of Daily Living (ADLs) on the sample list of 42 residents.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to verify proper gastrostomy tube placement by checking for gastric residual before administering medications for one of two residents (R6) reviewed for gastrostomy tubes in a sample of 42. On 5/4/2026 at 3:18 PM V15, LPN (Licensed Practical Nurse) administered medications to R6 via gastrostomy tube (g-tube). Medications administered were Gabapentin capsule 100 mg (milligram) one capsule and Docusate Sodium 100 mg 1 tablet. R6 was to receive 30 cc (cubic centimeter) of water flush before and after administering medication. V15 inserted the syringe with 30cc of water into R6's gastrostomy tube, pushed the water into the g-tube removed the syringe placed the prepared medications into the syringe and re-inserted into the gastrostomy tube and administered the medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light was maintained in good working order. This failure affects one (R14) of 32 residents reviewed for call lights on a sample list of 42 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received the correct medication in accordance with their physician orders, one (R3) of four residents reviewed for medication administration, in a sample of 14 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean environment for one (R4) of five residents reviewed for housekeeping on the sample list of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R6 and R7) reviewed for abuse in the sample of three. On 12/23/2025 at 1:15 PM V1, Administrator, provided an investigation file documenting a physical altercation between R6 and R7. The Abuse Investigation file dated 8/8/25 documents a physical altercation between R6 and R7. The file documents R6's statement of the incident involving R7 stating that R6 was grabbed and punched by R7 in the left arm. It documents R6 returned a punch hitting R7. On 12/23/2025 R6's care plan review documents R6's admission to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment that was clean and free from environmental hazards for thirteen (R1, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) of nineteen residents reviewed for Physical Plant Problems on a sample list of nineteen.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure relieving interventions and re-evaluate the effectiveness of a pressure ulcer treatment when the wound did not improve for one of three residents (R2) reviewed for pressure ulcers in the sample of five.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure utensils, dishes, and cookware were sanitized prior to serving foods to residents, failed to prevent cross contamination of foods from staff clothing during meal service, and failed to maintain a cooking environment free from debris. This failure has the potential to affect 107 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to hold one quarterly Quality Assurance Performance Improvement (QAPI) meeting for the 2024 year and failed to include the facility's Infection Preventionist in all QAPI meetings. This failure has the potential to affect all 107 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a risk assessment plan for Legionella and failed to prevent cross contamination during medication administration. These failures have the potential to affect all 107 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to employ an Infection Preventionist (IP). This failure has the potential to affect all 107 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide clean and debris free heaters and a clean and hole free privacy curtain for five (R7, R17, R20, R36 and R41) of five residents reviewed for a clean, homelike environment from a total sample list of 35 residents.

Inspectors wroteBased on interview and record review the facility failed to provide notifications of discharge for two (R20 & R101) of two residents reviewed for discharge from a total sample list of 35 residents.

Inspectors wroteBased on interview and record review the facility failed to provide bed hold notices for two (R20 & R101) of two residents reviewed for transfers from a total sample list of 35 residents.

Inspectors wroteBased on interview and record review the facility failed to complete a Pre-admission Screening and Resident Review (PASARR) level I for one (R45) resident out of one resident reviewed for PASARR level I in a sample list of 35 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent two stage two pressure ulcers from developing, failed to prevent cross contamination during pressure ulcer care, and failed to implement dietary interventions for wound healing timely for three (R41, R6, & R352) of seven residents reviewed for pressure ulcers from a total sample list of 35 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's personal electric fan was assessed for safety before use and failed to ensure a resident was safely positioned in bed to prevent a fall for two of two residents reviewed for accidents in the sample list of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during perineal care for one (R6) resident out of one resident reviewed for perineal care in a sample list of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to check the placement of a Gastrostomy tube prior to administering fluids and medication for one of one resident (R40) reviewed for Gastrostomy tubes in a sample list of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a behavioral plan to address self-harming behaviors for one (R20) of one resident reviewed for behavioral health services from a total sample list of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications according to the physician order for one of seven residents (R90) reviewed for medication administration in the sample list of 35 residents. The facility had three medication errors out of 28 opportunities resulting in a 10.71% error rate.

Inspectors wroteBased on interview and record review the facility failed to offer a pneumonia vaccine for one (R352) of five residents reviewed for immunizations from a total sample list of 35 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a physician order STAT (immediate) for orthopedic consult appointment, in a timely manner, for a resident (R1) with a right Humerus fracture. This failure resulted in a six day delay, which caused severe pain and swelling before the application of a cast could occur. This failure affected one of three residents (R1) reviewed for falls/physician orders on the sample list of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe environment and implement fall interventions which resulted in R3 falling out of bed and hitting her head on the bedside dresser on two separate occasions, both required emergency medical attention for head lacerations requiring closer with staples. The facility also failed to provide adequate assistance and a safe environment during resident ambulation, resulting in R1 sustaining a right arm fracture. These failures affected two of three residents (R1, R3) reviewed for falls on the sample list of six. Findings Include: 1. R3's Medical Diagnosis List dated March 2025 documents R3 is diagnosed with Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominate side, Restlessness and Agitation, Anxiety, Restless Leg Syndrome, and Insomnia. [...]

Inspectors wroteBased on observation, interview and record review the facility failed repeatedly to maintain accurate and complete medical records for one of five residents (R1) reviewed for documentation on the sample list of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor a resident's right to choose when to have a shower and when the administration of a wound dressing would be changed. This failure affects one of three (R1) residents reviewed for resident rights/wound dressings on the sample list of six.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' right to be free from verbal abuse when a staff member (V12) refused to assist a resident (R4) with a requested transfer, ambulation, and toileting hygiene. This failure affects one of three residents (R4) reviewed for abuse on the sample list of six.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a dependent residents shower and wound dressing change, prior to a doctor's appointment. This failure affected one of three residents (R1) reviewed for shower/wounds on the sample list of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' right to a clean, comfortable, environment and quality of care by failing to maintain an adequate supply of towels and washcloths to meet the needs of the residents. This failure has the potential to affect all 104 residents that reside in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure utility rooms and nurses stations were clean, in good repair, and free of debris. This failure has the potential to affect all 105 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services were provided by a Registered Nurse for eight consecutive hours per day. This failure has the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service. This failure has the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow posted/printed menus. This failure has the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms are clean and free of debris and the walls are in good repair. This failure affects five (R6, R7, R2, R8, R4) of eight residents reviewed for environment on the sample list of eight.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for wound healing and failed to apply wound treatments for two (R1, R3) of three residents reviewed for pressure ulcers on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to have physician orders for oxygen use for three (R1,R2, and R5) of five residents reviewed for oxygen in the sample list of five.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. This failure has the potential to affect all 95 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow participation in a dietary assessment, failed to allow participation with an advance directive choice, and failed to obtain consent for psychotropic medications for four (R28, R198, R78, and R11) of 24 residents reviewed for choices on the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with personal hygiene, a transfer out of bed, and set up help at a meal for five (R28, R37, R198, R13, and R65) of 24 residents reviewed for activities of daily living on the sample list of 46.

Inspectors wroteThis failure resulted in two deficient practice statements. A. Based on observation, interview, and record review the facility failed to provide supervision while smoking for eight of eight (R91, R53, R48, R2, R9, R43, R63, and R6) residents reviewed for smoking on the sample list of 46. B. Based on observation, interview, and record review the facility failed to thoroughly investigate falls to determine root cause and implement post fall interventions for two (R64, R78) of four residents reviewed for falls in the sample list of 46.

Inspectors wrote3.) R11's Order Summary Report dated 2/25/24 documents diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Pneumonitis Due to Inhalation of Food and Vomit and Unspecified Cerebrovascular Disease. These orders do not document any orders for oxygen administration or orders to change the oxygen tubing. On 2/25/24 at 9:08 AM, R11 was in bed with a mattress on the floor next to the bed R11 had oxygen on via nasal cannula with the oxygen concentrator set on 3 liters. On 2/26/24 at 10:29 AM, R11 was in bed with the oxygen concentrator running and the oxygen tubing and nasal cannula were laying on the floor. R11 was lying in bed sleeping. R11's Care Plan with an initiated date of 11/23/23 documents R11 has oxygen therapy related to diagnoses of Acute/Chronic Respiratory Failure with Hypoxia with an intervention of oxygen via nasal cannula per Physician order. On 2/28/24 at 9: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the safety of self-administration of medications for two of two residents (R58, R44) reviewed for self-administration of medication on the sample list of 46. Findings Include: The facility's Resident Self Administration of Medication policy with a revision date of 1/24/23 states, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be administered safely. This policy also states, The results of the interdisciplinary team assessment are recorded on Medication Self-Administration form, which is placed in the resident's medical record. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the use of a restraint, obtain physician orders, and develop a care plan for restraint use for one of one resident (R70) reviewed for restraints in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and record daily weights as ordered for one (R64) of 24 residents reviewed for physician's orders in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a vision assessment and provide vision services for one (R76) of 24 residents reviewed for vision on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to implement interventions to prevent pressure ulcers for one (R26) of four residents reviewed for pressure ulcers in a sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain catheter orders, provide routine catheter care, maintain a urinary catheter drainage bag in a sanitary manner, follow up on a urinary tract infection, and develop a care plan to address isolation related to a urinary tract infection for two (R65, R76) of five residents reviewed for urinary care in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate and attempt to restore eating skills, administer G-tube (Gastrostomy tube) feedings per physician's orders, check G-tube placement prior to use, document feeding intakes, and ensure the head of the bed was elevated when administering feeding for three of three residents (R49, R65, R28) in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to document targeted behaviors and nonpharmacological intervention responses to support the use of psychotropic medications, periodically assess for the use of psychotropic medications, complete AIMS (Abnormal Involuntary Movement Scale) assessments, and attempt gradual dose reductions (GDRs) or document clinical rational to justify maintaining the dose for five of five residents (R78, R92, R8, R10, R11) reviewed for unnecessary medications in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a facility wide system to account for residents exiting and returning to the facility and failed to provide adequate supervision for two residents (R1, R2) of three residents reviewed for elopement in a sample list of three residents. These failures resulted in (R1) eloping from the facility without knowledge of facility staff as to (R1's) whereabouts for over 20 hours. R1 was located at (R1's) former residence, 0.3 Miles (per Internet Map) from the facility, which required R1 to cross an undivided four-lane roadway. The Immediate Jeopardy began on 2/1/24 at 9:29PM when R1 left the facility, unattended, in the dark and in the cold. V1, Administrator was notified of the Immediate Jeopardy on 2/13/24 at 4:53PM. [...]

Inspectors wroteBased on interview and record review the facility failed to complete Certified Nursing Assistant performance reviews/evaluations to identify training needs and implement training. This failure has the potential to affect all 95 residents who reside in the facility. Findings Include: The facility's midnight census report dated 2/7/24 documents 95 residents reside at the facility. The Facility's Assessment tool (not dated) documents, Skills competencies are completed upon hire and annually to ensure all employees have and maintain necessary skills to provide high quality care to residents in all departments. The nursing department complete competencies on their personnel monthly on various topics to ensure all skills are maintained throughout the year. On 2/7/24 V1, Administrator stated, We do not do annual evaluations of our staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a physician document in R4's medical record at the time of transfer from the facility to the hospital R4's specific needs the facility could not meet, the facility attempts to meet R4's needs, and how the receiving facility could meet R4's needs. This failure affects one resident (R4) of three reviewed for discharge in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to follow their bed hold policy allowing a resident to return to the facility following hospitalization. This failure affects one resident (R4) of three reviewed for discharge.

Inspectors wroteBased on interview and record review, the facility failed to administer prescribed pain medication to a resident in a timely manner. This failure affects one resident (R1) on the sample of eleven residents reviewed for abuse/medications. This failure resulted in R1 experiencing excruciating pain for twelve hours in the facility following a partial foot amputation requiring hospitalization for pain management and medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen dishwashing room in a sanitary manner. This failure has the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain their industrial dryers in a safe operating condition. This failure has the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve meals at an appropriate temperature to residents eating meals in their own rooms. This failure affects nine residents (R3, R5, R7, R8, R9, R10, R11, R12, and R13) out of eleven interviewed for meal temperatures in a total sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for fire and burn hazards by utilizing portable space heaters throughout the facility. This failure has the potential to affect all 94 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical abuse. This failure affects one resident (R1) of three reviewed for abuse in the sample of five.

Inspectors wroteBased on interview and record review, the facility failed to update and revise resident care plans following a resident-to-resident altercation. This failure affects two residents (R1 and R2) of three reviewed for abuse in the sample of five.

Inspectors wroteBased on interview and record review, the facility failed to fully document the details of a resident-to-resident physical abuse allegation and investigation in residents' medical records. This failure affects two residents (R1 and R2) of three reviewed for abuse in the sample of five.

Inspectors wroteBased on interview and record review the facility failed to properly screen employees for illnesses affecting four (R1, R2, R4 and R8) of four residents reviewed for infection control.

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of two (R1, R4) of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough investigation of an abuse allegation for one (R1) of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide feeding assistance for lunch for four residents (R8, R9, R10, R11) of four residents reviewed for feeding assistance in the sample list of 16.