Decatur Medical Lodge

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #14 and Resident #109) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #14 and Resident #109. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for two (Resident #96 and Resident #34) of 5 residents, reviewed for positioning during meals. The facility failed to ensure CNA A correctly positioned Resident #96 for feeding. The facility failed to ensure CNA E correctly positioned Resident #34 for feeding. This failure placed residents at risk for aspiration and choking due to poor positioning while eating.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for one (Resident #63) of 8 residents, reviewed for puree' meals. The facility failed to ensure [NAME] F correctly prepared a puree' meal for Resident #63. This failure placed residents at risk for aspiration and choking due to food not being prepared correctly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1. The facility failed to ensure food items in the dry storage room were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards. The facility failed to ensure food items in the walk-in freezer were properly stored, sealed, and protected from exposure to air. These failures could place residents at risk for food-borne illness, cross contamination, and infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment one (Resident #2) of 4 residents, reviewed for PASARR. The facility failed to ensure the MDS Coordinator referred Resident #2 for a PASARR evaluation or PASARR Level 2 screening. This failure placed residents at risk of not receiving PASARR services they could potentially receive.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure each resident received adequate supervision and assistance devices to prevent accidents for residents for 1 (Resident #13) of 5 residents reviewed for devices. The facility failed to maintain Resident #13's manual wheelchair, which was missing the right-hand armrest and had a cracked and worn left armrest, exposing he resident to possible skin breakdown. This failure could place residents at risk of being uncomfortable and of injury from equipment not properly maintained.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #86) of 5 residents, reviewed for infection control. The facility failed to ensure CNA I performed hand hygiene during incontinence care for Resident #86. This failure placed residents at risk for infection due to not performing hand hygiene.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received and were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for two of two residents (Resident #1 and #2) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Residents #1 and #2. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments for one of eight medication carts (Nurse med cart #1) in that: The facility's nurse medication cart (Nurse med cart #1) was left unlocked, unattended, and out of LVN B's view outside room [ROOM NUMBER] on 02/04/25. This failure placed residents at risk of their medications being stolen or misused and health complications related to accidental ingestion of drugs and/or biologicals, including hospitalization and death

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #3 and Resident #81) reviewed for infection control in that: 1. CNA A failed to put on Personal Protective Equipment (PPE) while providing perineal care to Resident #3, who is on EBP. 2. LVN B failed to put on PPE while administering medications and tube feeding via G-tube for Resident #81 who was on EBP for G-tube (a g-tube is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have difficulty swallowing). [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 2 of 4 residents (Resident #4 and Resident #19) reviewed for care plans in that: The facility failed to ensure that Resident #4 and Resident #19 use of bed rails/grab bars/mobility bars/transfer bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #81) of 4 residents reviewed for enteral nutrition in that: 1. LVN B failed to obtain physician orders for water to flush Resident #81's G-tube before medication administration and after medication administration via the G-tube. 2. LVN B failed to hold tube feeding for 30 minutes after medication administration for Resident #81 per facility policy. 3. LVN B pushed all medication and water with a syringe and plunger instead of using gravity gentle flow (this is a method used by attaching a feeding syringe without the plunger to allow water, medications and food to enter the stomach vis G-tube gently without force of pushing) to administer medications and water via G-tube for Resident #81. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails and grab bars with the resident or resident representative or obtain informed consent prior to installation for one (Resident #4) of four resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent and assessment of the resident for risk of entrapment for bed rails or grab bars for Resident #4. This failure could place residents who used bed rails/grab bars at risk of the resident not being assessed for bed rails or grab bars, resident/responsible party not being aware of the risks, and informed consent not being obtained from the resident or responsible party.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure Resident #1's oxygen tubing was dated. This failure placed the residents at risk for infections and respiratory related complications.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for one (Resident #1) of eight residents reviewed for notification. LVN A failed to notify Resident #1 physician after resident fell in her room on 04/17/24. LVN A failed to notify Resident #1's responsible party after Resident# 1had a fall in her room on 04/17/24. These failures could place residents at risk for delayed physician intervention and risk of families not receiving notification of change in condition of residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to date and label food items in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for one (Hall 400) of four halls. The facility failed to keep the environment free of flies. This failure could affect residents by placing them at risk for the potential spread of infection, food-borne illness, and decreased quality of life. Review of Resident #57's face sheet, dated 12/13/2023, reflected he was a [AGE] year-old male, admitted on [DATE] with diagnoses of unspecified dementia with behavioral disturbance, heart disease, and history of stroke. Review of Resident #57's MDS assessment, dated 12/05/23, reflected he was usually able to understand others and to be understood by them. He had a BIMS score of 14, indicating intact cognition. Resident #57 exhibited no behaviors or psychosis during the assessment period. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was prepared in a form designed to meet individual needs for one (lunch) of two meals reviewed. Cook C failed to ensure the puree bread was prepared to the desired consistency. This placed residents at risk, who received pureed meals from the kitchen, of choking.

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for the facility's main dumpster reviewed for garbage disposal. 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest and failed to ensure garbage dumpster lids remained closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (Residents #64) of 10 residents reviewed for infection control. The facility failed to ensure CNA D washed her hands after barehanded carrying a dirty tray out of a communicable disease isolation room for Resident #242, before barehanded touching Resident #64's bedside table, and barehanded touching Resident #64's call light. The facility failed to ensure CNA D sanitized her hands after exiting Resident #64's room. This failure could place residents at risk of communicable infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 of 3 residents (Resident #1, and #2) reviewed for pharmacy services and medication administration by two CMA (CMA A, CMA B) in that: The facility failed to give mediations in a timely manner for several medications scheduled at 7:00AM , 7:30AM and 9:00AM for Resident #1 and #2 the morning of 11/29/2023 during medication pass with CMA A and CMA B. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident and hazards as was possible for one resident (Resident #1) of three residents reviewed for accidents and hazards. Driver C failed to follow proper safety measures in securing Resident #1 in the van while driving the resident. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk of severe injury or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatments and supports for daily living safely for 1 of 26 residents that reside on Hall 100 reviewed for environment. The facility failed to ensure the hallway carpet on Hall 100 was not frayed. This deficient practice could place residents at risk for a diminished quality of life and a diminished clean and homelike environment.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident #1) of eight residents reviewed for abuse and neglect reporting. The Administrator failed to report an incident which occurred when Driver C was driving Resident #1 to an appointment without her seatbelt on, and the resident fell, bumping her head (no injury) and sustaining a skin tear to her forearm. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for one (Resident #1) of eight residents reviewed for abuse and neglect reporting. The Administrator failed to report an incident which occurred when Driver C was driving Resident #1 to an appointment without her seatbelt on, and the resident fell, bumping her head (no injury) and sustaining a skin tear to her forearm. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care for one meal (Lunch on 09/27/23) observed for frequency of meals. The facility failed to serve the 09/27/23 lunch meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life.