Decatur Health & Rehab Center

Inspectors wroteBased on interviews, record review, and the facility's policy titled Notification of Changes, the facility failed to ensure Resident Identifier (RI) #497's physician was notified when RI #497 experienced a change in condition on 01/04/2025 at 1:24 PM when RI #497 had an elevated heart rate (HR) of 142 beats per minute (bpm). The facility further failed to notify the physician on 01/04/2025 at 9:22 PM when RI #497's heart rate continued to be elevated at 120 bpm. As a result of RI #497's physician not being notified upon the change in condition, no additional treatment or interventions were implemented which resulted in delayed treatment that was likely to result in serious injury, serious harm, impairment, or death. [...]

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #497's medical records, and hospital record review, the facility failed to ensure: 1.) licensed staff followed standards of practice when Licensed Practical Nurse (LPN) #10 failed to completely and accurately transcribe an order. Specifically, on 01/04/2025 at 1:24 PM RI #497's HR was 142 beats per minute (bpm). LPN #10 notified Certified Registered Nurse Practicioneer (CRNP) #15 and received orders to check the resident's heart rate (HR) manually twice per day and send RI #497 to the emergency room (ER) if RI #497's HR did not decrease. LPN #10 entered into the electronic system for the manual HR assessment to begin at 8:00 PM and failed to transcribe the order to send the resident to the ER if the HR did not decrease. [...]

Inspectors wroteBased on interviews and resident record reviews the facility failed to ensure: 1) a system was in place to ensure newly admitted residents vital signs were assessed at a frequency expected by the Physician/Certified Registered Nurse Practitioner (CRNP); and 2) resident specific vital sign parameters were established including when the physician should be notified of abnormal values. Specifically, RI #497 was admitted to the facility on [DATE] after being admitted to the hospital on [DATE] with Atrial Fibrillation with RVR (Rapid Ventricular Response). The facility's orders indicated RI #497's vitals were to be assessed every month and no parameters were established. The physician/CRNP reported they expected vitals to be assessed at least daily for newly admitted residents. On 01/04/2025 at 1:24 PM RI #497's heart rate (HR) was 142 beats per minute (bpm). [...]

Inspectors wroteBased on observation, interview, the facility's policies for Food Safety Requirements and Date Marking for Food Safety, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure frozen chicken was safely thawed and two boiled eggs in the Reach-in Cooler had a use-by date on 01/27/2025. This had the potential to affect 100 of 100 residents receiving meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, the facility's policy for Disposal of Garbage and Refuse, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure two of two dumpsters were closed and food-related trash was not strewn on the ground around the dumpster area on 01/27/2025. This had the potential to affect 100 of 100 residents receiving meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure the Tilt Skillet and the Double Steamer were in working order and had not been inoperable for over a year. In addition, there was an operation issue with the two Stove Ovens. This had the potential to affect 100 of 100 residents receiving meals from the facility's kitchen.

Inspectors wroteBased on interviews, resident record review, review of a facility investigative file, review of an Online Facility Reported Incident (FRI), review of a facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to protect Resident Identifier (RI) #547's right to be free from abuse on 08/23/2024 when Licensed Practical Nurse (LPN) #21 was witnessed telling RI #547, a newly admitted resident with Dementia, to shut the fuck up. This was witnessed by Certified Nursing Assistant (CNA) #22, CNA #23, and CNA #24. Staff stated that what LPN #21 said to RI #547 was verbal abuse and would make someone in that situation feel afraid. The facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, past noncompliance was cited. [...]

Inspectors wroteBased on record review, interviews, and the facility's policy titled, admission Orders the facility failed to ensure an order for the use of oxygen was obtained for Resident Identifier (RI) #497 upon admission to the facility on [DATE]. This deficient practice affected one of 37 residents for whom physician's orders were reviewed. Findings Include: Review of the facility's policy titled, admission Orders, with a revised dated of 12/31/24, revealed the following: . Policy . A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs . Policy Explanation and Compliance Guideline: 1. The written and/or verbal orders should include . b. Medication orders if indicated . 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's . [...]

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #38's completed Minimum Data Set (MDS) assessment was transmitted to the CMS system. This affected RI #38, one of 29 sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled Documentation in Medical Record, the facility failed to ensure Resident Identifier (RI) #447's Medication Administration Records (MAR) accurately reflected administration of insulin administered to RI #447. Licensed Practical Nurse (LPN) #27 documented she administered Lantus Insulin on RI #447's MAR when she did not administer the insulin. This deficient practice affected RI #447, one of 29 sampled residents.

Inspectors wroteBased on observations, interviews, and review of a facility policy titled Infection Prevention and Control Program, the facility failed to ensure a Licensed Practical Nurse (LPN) #20 administered medications and obtained vital signs in a manner to prevent the spread of infection between himself and residents; and resident to resident. LPN #20 handled Resident Identifier (RI) #61's medication with his bare hands and LPN #20 failed to clean, disinfect, and properly store equipment used for obtaining resident vital signs prior to using the equipment on RI #70. These deficient practices had the potential to affect RI #61 and RI #70, two of 29 sampled residents.

Inspectors wroteBased on record review, interviews, the facility's VERIFICATION OF INVESTIGATION, a review of the Alabama Department of Public Health Online Incident Reporting System, a review of facility's policies titled Resident Elopement, and Resident-Missing the facility failed to ensure adequate supervision was provided to Resident Identifier (RI) #1 to prevent and identify elopement. On 09/14/2023 around 5:35 PM, RI #1, a resident with cognitive deficits, eloped from the facility. Certified Nursing Assistant (CNA) #5 identified that RI #1 was not in his/her room around 6:00 PM and did not act to locate RI #1, but assumed he/she had discharged home. At 8:47 PM, Licensed Practical Nurse (LPN) #8 identified that RI #1's whereabouts were unknown and initiated action to locate RI #1. At 8:57 PM, RI #1 was found by local law enforcement at a grocery store located 1.9 miles away. [...]

Inspectors wroteBased on record review, interviews, and review of a facility policy titled Skin- Body Audit of Resident, the facility failed to ensure Resident Identifier (RI) #158's twice weekly body audits were documented as completed, in accordance with the facility's policy and procedure. This affected RI #158, one four sampled residents reviewed for skin concerns. Findings Include: A review of the facility's policy titled Skin- Body Audit of Resident, last revised 02/28/2020, revealed: Purpose To monitor for and identify any resident skin conditions. Policy The Skin/Body Audit of residents should be done two (2) times weekly . Procedure . 6. Examine . i. Any areas of concern should be written on the Skin/Body Audit Record Form, Form #098 or # 274 . RI #158 was admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interviews, medical record review, and a review of the facility's policy titled Changes - Notification Of the facility failed to ensure: 1) the physician was notified upon admission when Resident Identifier (RI) #158 was identified as having a left heel bruise and redness to the left posterior calf before the Registered Nurse (RN) initiated treatment; and 2) RI #158's family was notified on 02/23/2021 when the nurse initiated a new treatment. Further, the facility did not notify the family of changes to the wound, or on 03/10/2021, 03/17/2021, or 03/25/2021 when new orders for treatment changes occurred. This affected RI #158, one of three sampled residents who were reviewed for proper notifications. Findings Include: A review of the facility's policy titled, Changes - Notification Of, revised 02/01/2015, revealed the following: Purpose The facility shall promptly notify . [...]

Inspectors wroteBased on interviews and medical record review, the facility failed to ensure Resident Identifier (RI) #158's care plans were updated to reflect the need for supplemental padding due to skin redness identified under RI #158's left knee immobilizer. This affected RI #158, one of 27 sampled residents for whom care plans were reviewed. Findings Include: RI #158 was admitted to the facility on [DATE] with diagnoses including: Periprosthetic Fracture Around Internal Prosthetic Left Hip Joint and Muscle Weakness (generalized). Review of an .Order Form from the time of RI #158's transfer from the hospital to the facility revealed RI #158 was to remain non-weightbearing for 8 weeks post-op (surgical repair of fractured hip) and was required to wear a motion control brace at all times while transferring and upright, except while sleeping. This . Order Form listed the following: . [...]

Inspectors wroteBased on observation, interview, record review, and review of a facility policy titled Nebulizer Treatment - Hand Held Aerosol, the facility failed to ensure Resident Identifier (RI) #44's nebulizer tubing was changed weekly. This affected one of one resident who was observed receiving a nebulizer treatment. Findings Include: Review of a facility policy titled Nebulizer Treatment - Hand Held Aerosol, 01/18/2019, revealed: . Procedure . 2. Care of the Equipment . h. Change nebulizer tubing weekly and prn (as needed). RI #44 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of RI #44's Physician Orders for the month of April 2021 revealed an order dated 04/18/2019 to . CHANGE NEBULIZER TUBING EVERY SEVEN DAYS ON THIRD SHIFT WHEN IN USE . [...]