Decatur Center for Nursing and Healing LLC

Inspectors wroteBased on observations, staff Interviews, and review of the facility policy titled, Disposal of Garbage and Refuse, the facility failed to ensure garbage and waste refuse was properly disposed of at the Dumpster site; failed to ensure garbage and refuge receptacle containers were covered and failed to ensure dumpster area was clean and free of debris. These failures posed a sanitation hazard with the potential for insect and rodent attractions.

Inspectors wroteBased on observations, staff and resident interviews, and review of the facility policies titled, Preventative Maintenance Program and Linen Operations and Management: The Linen Operation, the facility failed to ensure the environment was maintained in a safe, sanitary, and functional condition. Specifically, Packaged Terminal Air Conditioner (PTAC) air filters in two of ten rooms (rooms [ROOM NUMBERS] on Team A Hall) were observed to contain a significant amount of gray, fuzzy particulate matter. Additionally, clean linens were not consistently available for resident care for six of 47 sampled residents (R) (R39, R8, R101, R89, R90, and R72). The deficient practice had the potential to contribute to respiratory problems for residents due to unclean air filters and to delays in care due to insufficient linen availability.

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Accidents and Incidents and Preventative Maintenance Program, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility failed to maintain environmental surfaces in a safe condition and failed to implement interim measures to mitigate identified hazards, including a broken handrail with exposed, jagged edges on one of two hallways on the first floor, and a loose, rusted heater cover with sharp edges accessible to residents in one of two shower rooms (first floor central shower room). These conditions had the potential to cause injury, including skin tears and lacerations.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Hand Hygiene, the facility failed to ensure staff adhered to appropriate infection control practices during the handling and disposal of contaminated waste. This deficient practice had the potential to increase the risk of infection transmission through cross-contamination.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Sanitation, Refrigeration and Freezers, and Food brought by Family/Visitors, the facility failed to maintain cleanliness for two of the two ice machines and failed to properly store food items in two of the two refrigerators and freezers on the units (First and Second Floor). This deficient practice had the potential to affect residents who received an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled How to Puree Foods, the facility failed to follow a recipe, use measuring devices, and use utensils when preparing puree food. This deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increase risk of aspiration for seven of seven residents receiving a puree diet.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, the facility failed to assure that the advance directive status was consistently documented in the clinical record for one out of 43 sampled Residents (R) (R167).

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled Heating, Ventilation and Air Conditioner (HVAC) Packaged Terminal Air Conditioner (PTAC): Clean air filters, the facility failed to maintain clean PTAC unit grills for two out of 32 Rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the First floor. This deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections.

Inspectors wroteBased on observations, record review, staff interviews and review of the facility's policy titled Medication Administration, the facility failed to provide services that meet professional standards by not ensuring one out of eight Residents (R) (R10) received the correct medication dosage that was observed during medication administration. This deficient practice had the potential to cause adverse medication effects and medication error.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide nail care for one out of three Residents (R) (R45) reviewed for Activities of Daily Living. This failure had the potential to affect the resident's comfort, body image, and increase the risk of infections.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to follow physician orders for oxygen administration one Residents (R) (R45) and to properly store the oxygen nasal cannula when not in use for R96 out of 15 residents on oxygen. This deficient practice had the potential to cause respiratory distress and infection.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Medication Storage, Labeling of Medications and Biologicals, and Use by Dating Guidelines, the facility failed to lock two of six medication carts on the 100 and 200 halls. In addition, the facility failed to have an open date on one bottle of glucometer strips in one of six medication carts on the 200 hall and failed to remove six bottles of expired nutritional supplements from one of two medication rooms.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled Glucometer Disinfection and Infection Prevention and Control Program, the facility failed to disinfect the glucometer machine after it was used to check blood sugar for one out of eight Residents (R) R50 observed during medication administration. This deficient practice had the potential to increase the risk of infection transmission and compromise the overall health of residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure one of one garbage dumpsters had a tightly fitted lid. In addition, the facility failed to ensure the sliding door was kept close when not in use. The facility census was 123 residents.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure that opened food stored in one walk-in cooler was covered, labeled and dated. This failure had the potential to affect 121 of 123 residents who received an oral diet from the kitchen.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of four sampled residents (R) (R12) reviewed for falls.

Inspectors wroteBased on interviews, record review and review of the facility's policy titled Medication Administration, the facility failed to administer scheduled medication within 60 minutes before or after the scheduled medication time for one of sampled three residents (R) (R13) reviewed for medication administration.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to provide showers/baths for one of six sampled residents (R) (R12) reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observations and interviews the facility failed to provide a safe homelike environment for residents on two of two floors. The tour of the facility revealed trash debris in residents' rooms and bedroom furniture in disrepair. This failure had the potential to place residents at risk for use of unsanitary and a unsafe environment and a potential for diminished quality of life.

Inspectors wroteBased on staff and resident interviews, record reviews, and a review of facility's policy titled, Care Plans - Baseline, the facility failed to develop base line care plans for six residents of 35 sampled residents (R) (#67, #92, #105, #117, #279, and #280). This failure had the potential to place newly admitted residents at risk of not receiving necessary care and services.

Inspectors wroteBased on staff interview, record review, and a review of the facility's policy titled, Resident Rights, and Care Planning-Interdisciplinary Team, the facility failed to ensure a care conference was held on a regular basis with the resident or resident representative for one of three sampled residents (R) (#94) reviewed for care conferences. This failure had the potential to place residents at risk for unmet care needs.

Inspectors wroteBased on staff interview, record review, and a review of the facility's policy titled, Resident Assessment Instrument (RAI), the facility failed to electronically transmit Minimum Data Set (MDS) data to the CMS [Center for Medicare and Medicaid] system for one of 35 sampled residents (R) (#21) whose MDS data was reviewed. The facility failed to transmit an 11/08/2022 Discharge-Return Not Anticipated for R#21.

Inspectors wroteBased on staff and resident interviews, record review, and a review of the facility's policy titled, Comprehensive Care Plans review, the facility failed to ensure that one of 35 sampled residents (R) (#43), care plan was revised to reflect R#43's current full-code status. This failure placed the resident at risk for delayed response time and potential for her life saving preferences not to be followed.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Urinary Catheter Care the facility failed to ensure one of 35 sampled residents (R) (#117) received the appropriate care to prevent urinary tract infections. While providing incontinent care to R#117 a staff member was observed not to use proper hand hygiene and failed to provide proper catheter care.

Inspectors wroteBased on observation, staff interviews, and a review of facility's policy titled, Nebulizer Therapy, the facility failed to provide a nebulizer treatment in accordance with professional standards for one of 35 sampled residents (R) (#117). The nurse failed to assess the resident's lung sounds pre- and post- administration of nebulizing treatment. The facility failed to assess the effectiveness of the nebulizer treatment for the resident.

Inspectors wroteBased on staff interviews, record reviews, and a review of the facility's policy titled, Dialysis: Hemodialysis (HD)-Communication and Documentation, the facility failed to provide dialysis care and services to meet the needs of two of two sampled residents (R) (#45 and #105) reviewed for dialysis. The facility failed to provide ongoing assessment and monitoring of the dialysis access fistula/catheters. This failure had the potential to place the residents at risk for complications before and after dialysis treatments.

Inspectors wroteBased on staff interview, record review, and a review of the facility's policy titled, COVID-19 Vaccination, the facility failed to ensure one of five sampled residents (R) (#49) who were reviewed for immunizations, had his COVID-19 vaccination status identified upon admission. This failure had the potential to place the resident at risk of acquiring and/or transmitting a contagious disease.