Decatur Rehab & Health Care Ct

Inspectors wroteBased on observation, interview, and record review the facility failed to provide notice which included date of transfer, discharge location, Office of the State Long Term Care Ombudsman contact information, appeal rights, and contact information for the agencies for advocacy and protection of residents with intellectual/development disabilities and mental illness for four (R1, R2, R3, R4) of four residents reviewed for involuntary transfer in the sample list of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate and document discharge planning for four (R1, R2, R3, R4) of four residents reviewed for involuntary transfer in the sample list of four.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor, implement pressure relieving interventions, complete treatments, and obtain weekly documentation for a pressure sore for one of one (R31) residents reviewed for pressure sores in a sample list of 34 residents. These failures resulted in R31's right heel pressure sore deteriorating requiring mechanical debridement and delaying prosthetic device placement for R31's Left Below the Knee Amputation. R31's Medical Record documents R31's medical diagnoses of Cardiomyopathy, Diabetes Mellitus Type II, Grade One Diastolic dysfunction, Severe Protein Calorie, Malnutrition, recent Left Below the Knee Amputation and Right Heel Stage 3 Pressure Ulcer. R31's undated Face Sheet documents R31 admitted to facility on 1/15/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were labeled and stored appropriately in the medication storage room and medication cart. This has the potential to affect all 39 residents who reside in the facility. Findings Include: 1. R15's Physicians Orders dated September 2024 documents an order for a Combivent Inhaler 20mcg (micrograms)/100mcg (inhaler) one puff four times a day. On 09/23/24 at 11:55 AM, V9 LPN (Licensed Practical Nurse) administered a Combivent Inhaler 20mcg/100mcg to R15. This inhaler was loose in the medication cart and did not contain a pharmacy label with R15's name or instructions for use. At this time, V9 stated I don't know where the label is for the medication, but V9 knows the inhaler belongs to R15 because R15 is the only resident that gets Combivent. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to employ a full time Certified Dietary Manager. This failure has the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the food products served were within the recommended date, failed to monitor food temperatures during meal service, failed to monitor temperatures and/or sanitizer level on dishwasher, failed to ensure to dishes were sanitized prior to resident use, failed to maintain sanitation practices in the facility kitchen, failed to monitor temperatures for the facility reach in cooler, reach in freezer, and chest freezer and failed to properly label and store foods. These failures have the potential to affect all 39 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to ensure it's antibiotic stewardship policy was comprehensive, and failed to track organisms and implement use of infection assessment tools. These failures have the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space for each resident in resident bedrooms. This failure affects all 39 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete resident assessments for four (R35, R36, R7, R27) of 12 residents reviewed for Minimum Data Sets (MDS) in the sample list of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and secure portable oxygen cylinders appropriately for five of five residents (R27, R20, R5, R29 and R13) reviewed for oxygen on the sample list of 34. Findings Include: On 9/25/24 at 10:24 AM, there were three oxygen cylinders sitting on the floor in the medication storage room, not secured or in a cart, along with three oxygen carts that had three oxygen cylinders in them. At this time, V3 Assistant Director of Nursing confirmed that three oxygen cylinders were not secured in a cart and should be. V3 also stated that the oxygen cylinders should not be stored in the medication storage room and explained all oxygen is supposed to be stored outside. The facility's undated Residents On Oxygen form documents R27, R20, R5, R29 and R13 all use oxygen.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications according to physician orders and manufacturer recommendations for four of 13 residents (R13, R24, R90, R31) reviewed for medication administration on the sample list of 34. The facility had five errors out of 26 opportunities resulting in a medication error rate of 19.23 percent.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure equipment is in good working repair, and the environment is clean and free of debris for three (R25, R26, R6) of 12 residents reviewed for safe homelike environment out of a sample list of 34.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse to the Abuse Coordinator for one of one resident (R4) reviewed for abuse in a sample list of 34 residents.

Inspectors wroteBased on interview and record review the facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASRR) after a new diagnosis of mental illness for one (R30) of three residents reviewed for PASRR in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive care plan for three (R35, R36, R37) of 12 residents reviewed for care plans in the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to provide restorative care services for one of three residents (R7) reviewed for restorative services in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain orders for Continuous Positive Airway Pressure (CPAP) settings and maintain hygienic care and storage of CPAP equipment for one (R36) of two residents reviewed for CPAP in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain consent, implement Gradual Dose Reductions, complete assessments, and track targeted behaviors for psychotropic medication use. These failures affect three (R21, R35, R37) of five residents reviewed for unnecessary medications in the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to provide palatable foods for two (R14, R22) residents out of two residents reviewed for palatable foods in a sample list of 34 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow a physician order to provide a pureed diet by not providing the appropriate consistency of pureed foods for one (R14) out of one resident reviewed for diet consistency in a sample list of 34 residents.

Inspectors wroteBased on interview and record review the facility to maintain documentation of influenza and pneumonia vaccination history and offer influenza and pneumonia vaccinations for two (R30, R35) of five residents reviewed for vaccinations in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an accessible working call light for one (R25) of twelve residents reviewed for call lights out of a sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses (DON). This failure has the potential to affect all 39 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (9/18/24) there was no Director of Nurses present and employed by the facility. On 9/20/24 at 2:58 PM, V1 (Administrator) confirmed the facility does not currently employ a full time DON. There has not been a full time DON employed by the facility since August 15, 2024. V1 confirmed the facility census is currently 39 residents. The Facility assessment dated [DATE] documents, a full time nursing supervisor (Director of Nurses) is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

Inspectors wroteBased on interview and record review the facility failed to treat one resident (R1) with respect of three residents reviewed for dignity in a sample list of three. Findings Include: R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM. On 8/19/24 at 10:19AM R1 stated I fell at home and broke my knee cap and my arm. Then I went to (the local hospital) and was sent to (the facility) The CNA's (Certified Nurses Assistant) here didn't know how much help I needed. There was once when a CNA on night shift (does not remember name) pulled my right arm. I told her I had broken that arm and the CNA stated 'no you didn't you just broke your left knee'. They were just generally uncaring and rude. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident room in a clean sanitary manner for two residents (R1, R2) of three residents reviewed for housekeeping in a sample list of three.

Inspectors wroteBased on interview and record review the facility failed to initiate a base line care plan and initiate resident centered interventions for one resident (R1) reviewed for Care Plans in a sample list of three. Findings Include: The facility's policy Baseline Care Planning revised 11/1/17 states It is the policy of (the facility) to promptly asses the plan (of) care for each resident admitted to the facility. Pending completion of the Comprehensive Resident Assessment and Care Plan, the interdisciplinary team shall asses each resident for potential needs. A Plan of Care (Baseline Care Plan) shall be developed to include instructions needed to provide effective person centered care to each resident, based on his/her initial assessment and professional standards of quality care, to serve as a functional guide in the delivery of care until such time as a comprehensive plan is developed. [...]

Inspectors wroteBased on observation and interview the facility failed to complete an admission Fall Risk Assessment for a resident with history of falls with injury. Ths failure affects one (R1) of three residents reviewed for falls in a sample list of three residents. Findings Include: The facility's policy Fall Prevention revised 11/10/18 states Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor resident's wishes/desires for maximum independence and mobility. Procedure: Conduct fall assessments on day of admission, quarterly, and with a change in condition. Identify, on admission, the resident's risk for falls. Assessment of fall risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. [...]

Inspectors wroteBased on interview and record review the facility failed to report abuse allegations timely to the administrator and report abuse allegations to the State Survey Agency (SSA) for five (R1, R3, R4, R5, R6) of six residents reviewed for abuse in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of sexual abuse for four (R1, R3, R5, R6) of six residents reviewed for abuse in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to care plan resident behaviors, develop behavioral interventions, and monitor behaviors. These failures affect four (R1, R3, R5, R6) of six residents reviewed for abuse in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to provide pain control and failed to transfer a resident with a broken femur to the hospital in a timely manner for one (R1) of three residents reviewed for falls in the sample list of three. This failure resulted in R1 remaining in the facility for ten hours while in pain with a broken left femur before being transferred to the hospital for pain control and care.

Inspectors wroteBased on interview and record review the facility failed to implement effective interventions to prevent falls with injury for one (R1) of three residents reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a fractured left hip.

Inspectors wroteBased on observation, interview, and record review the facility failed to employee the services of a full time Director of Nursing. This failure has the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure the right to a safe, clean, and homelike environment for seven (R10, R11, R12, R13, R14, R15, and R16) of 20 residents reviewed for environment on the sample list of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a room was equipped with a working toilet for seven (R4, R5, R6, R7, R8, R9, and R18) of twenty residents reviewed for toilets on the sample list of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop pressure ulcer plans of care for three of three (R1, R2, and R3) residents reviewed for care plans on the sample list of 20.

Inspectors wroteBased on interview and record review the facility failed to protect residents right to be free from verbal mental abuse by staff. This failure affects two (R1, R3) residents out of three residents reviewed for abuse in a sample list of four residents.

Inspectors wroteBased on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail which is to be delivered unopened on Saturdays. This failure affects all 42 residents which reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to employ a Full Time Director of Nurses. This failure has the potential to affect all 42 residents residing in facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space per resident bed in 28 of 30 resident rooms on 2 of 2 resident living corridors. 25 of these rooms were occupied by residents. This failure affects all 42 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to transmit minimum data set assessments in the required timeframe within 14 days after the assessment reference date. This failure affects six residents (R8, R15, R24, R30, R31, and R41) out of six reviewed for minimum data set transmission on the sample list of 44.

Inspectors wroteBased on interview and record review, the facility failed to certify the accuracy and completion of resident assessments by obtaining required Assessor and Coordinator signatures. These failures affect four residents (R8, R15, R30, R41) of six reviewed for resident assessments in the sample list of 44.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to maintain safe water temperatures to prevent the potential for scalding injuries on the facility's South Hall. This failure has the potential to affect 17 residents (R1, R4, R10, R11, R12, R13, R16, R22, R23, R24, R26, R31, R33, R34, R93, R243, and R244) residing on the South Hall from the sample list of 44. B. Based on interview and record review the facility failed to ensure a severely cognitively impaired resident (R245) was monitored to prevent elopement from the building. This failure affects one resident out of one resident (R245) reviewed for elopement in a sample list of 44 residents. C. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to complete Psychotropic Assessments and failed to obtain an end date for a Psychotropic medication. These failures affect four residents out of four residents (R4, R20, R24, R243) reviewed for unnecessary Psychotropic medications in a sample list of 42 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve bread as planned on the menu. This failure affected four residents (R12, R14, R15, R17) of 42 reviewed for diets in the sample list of 42 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during medication administration for three (R2, R4, R24) out of six residents reviewed for medication administration in a sample list of 42 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a handrail in the facility's North Hall in a manner securely attached to the wall. This failure had the potential to affect eight ambulatory residents (R5, R19, R25, R27, R28, R29, R144, and R145) residing on the North Hall from the sample list of 44.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by another resident and a staff member. These failures affect four residents (R26, R30, R244, R22) out of four residents reviewed for abuse in a sample list of 42 residents.

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse Prevention Policy by failing to promptly report allegations of verbal abuse to the Abuse Coordinator and by failing to suspend a staff member after an allegation of staff to resident verbal abuse. This failure affects three (R26, R30, R22) out of three residents reviewed for abuse in a sample list of 42 residents.

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse Prevention Policy by not reporting allegations of verbal abuse to the State Agency. This failure affects three (R26, R30, R22) out of three residents reviewed for abuse in a sample list of 42 residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct comprehensive annual and initial minimum data set assessments according to the required timeframe within 366 days. This failure affects three residents (R8, R30, and R41) out of six reviewed for annual assessments on the sample list of 44.

Inspectors wroteBased on interview and record review, the facility failed to complete a Level 2 PASARR (Preadmission Screening and Resident Review) within 40 days of admission for a resident admitted to the facility as an exempted hospital discharge. This failure affects one resident (R18) of one reviewed for admission screening in the sample list of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document any care plan focus area or non-pharmacological therapeutic interventions for a resident with diagnosed and exhibited symptoms of depression. This failure affects one resident (R41) out of two reviewed for behavioral and emotional indicators on the sample list of 44.

Inspectors wroteBased on observation, interview and record review the facility failed to properly date and store oxygen tubing for three (R33, R34, R243) residents out of three residents reviewed for respiratory care in a sample list of 42 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a social service assessment upon admission and conduct any therapeutic interventions for a resident with diagnosed and exhibited symptoms of depression. This failure affects one resident (R41) out of two reviewed for behavioral and emotional indicators on the sample list of 44.

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 42 residents residing in the facility.

Inspectors wroteBased on record review, observation and interview the facility failed to perform timely incontinence care to prevent shearing over R28's bilateral ischium (pressure ulcers), continued to implement nursing order while waiting for physician to be notified for a pressure ulcer treatment for two newly, facility acquired, Stage II pressure ulcers (shearing over bony prominence) 7/2/22-7/27/22 (25 days) and failed to measure the new, worsening pressure ulcers in accordance with facility policy for R28. These failures affected R28 and resulted in avoidable Stage II pressure ulcers with deterioration of the pressure ulcer as evidence by an increase in size. The facility also failed to ensure pressure relief device was in working order for R9. R9 and R28 are two of three residents reviewed for pressure ulcers on the sample list of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to lower R19's bed after providing cares and left R19 unattended in an elevated bed by resulting in a fall with serious injury and failed to complete neurological assessments for R19's fall. This failure resulted in R19 sustaining a fracture of the left wrist. R19 is one of three residents reviewed for falls on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on observation, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to close and seal stored food, failing to dispose of expired refrigerated food, failing to maintain a can opener in a sanitary operable condition, failing to maintain mixer blades, failing to maintain sanitary food preparation areas from grease, debris and dust, and failing to maintain a three-well sink free of paint chips, caulking, and dust. These failures have the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to hold quarterly Quality Assurance meetings and failed to ensure a Director of Nursing was present at these meetings. This failure has the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to designate a qualified and trained person to serve as Infection Preventionist. This failure has the potential to effect all 29 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to inform a resident (R2) on seven different occasions of missed administration of medications to prevent chest pain and failed to obtain informed psychotropic medication consent for R6. These failures had the potential to affect two of six residents (R2 and R6) reviewed for psychotropic/medications on the sample list of 21.

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's (R2) physician, on seven separate occasions, of missed administration of medication used for heart-related chest pain. The facility also failed to notify resident's (R3) physician of significant weight loss. R2 and R3 are two of two residents reviewed for physician notification of change in condition on the sample list of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive care plan for four (R3, R9, R15 and R25) of 21 residents reviewed for care plans on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, repeatedly that one resident (R14) had physician ordered, narcotic pain medication available to treat pain post a fall with fracture. R14 is one of one resident reviewed for pain on the sample list of 21.

Inspectors wroteBased on record review, observation and interview the facility failed to provide prescribed medication on seven separate occasions, for one (R2) of four residents reviewed for medication administration on the sample list of 21.

Inspectors wroteBased on record review, observation and interview the facility failed to prevent a significant medication error. The facility failed to administer a medication used for heart-related chest pain, as ordered by the physician. This failure was repeated on seven separate occasions for one (R2) of four residents reviewed during medication administration observation on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure residents' medications. This failure has the potential to effect eight (R1, R3, R6, R13, R16, R21, R29, R130) of eight residents reviewed for medication storage on the sample list of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident dignity was maintained during dining. This failure affected one (R10) of one resident reviewed for dignity on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to prevent the physical abuse of one resident (R25) by another resident (R7) for two (R25, R7) of three residents reviewed for abuse on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to request a re-screening of a Preadmission Screening and Resident Review (PASRR) after the current PASRR expired for one (R25) of three residents reviewed for PASRR on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to complete a discharge summary prior to discharge for one (R30) of one resident reviewed for discharge on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist with nail care for one (R9) of 16 residents reviewed for activities of daily living on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply an orthotic boot to help correct foot drop for one (R9) of one residents reviewed for range of motion on the sample list of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care, failed to perform incontinence care in a manner to prevent cross contamination and potential infection for R28, and failed to maintain R25's urinary indwelling catheter tubing off the floor to prevent cross contamination. R25 and R28 are two of four residents reviewed for bowel and bladder/catheter care on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident maintained a usual body weight and when weight loss continued, the facility failed to implement any new interventions to prevent, address, or treat the underlying cause of the weight loss which resulted in the resident experiencing a significant weight loss. This failure effected one (R6) of two residents reviewed for nutrition on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize a continuous airway pressure machine for one (R9) of one resident reviewed for sleep apnea on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to redirect a resident (R7) from the dining room when an escalation of behaviors occurred for one (R7) of one resident reviewed for behaviors on the sample list of 21. This failure resulted in an escalation from verbal to physical behaviors in the dining room in which R7 slapped R25 on the arm.

Inspectors wroteBased on observation, interview, and record review the facility failed to justify the use of an antibiotic for one (R25) of two residents reviewed for catheters on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to assess the need for psychotropic medications, complete quarterly psychotropic medication assessments, attempt gradual dose reductions, and failed to complete an abnormal involuntary movements scale. This failure effected two (R6, R15) of five residents reviewed for unnecessary medications on the sample list of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was provided assistive dining devices, according to the physician order. This failure affected one of four resident (R10) reviewed for dining/dignity on the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a bedroom door had the ability to open and close appropriately for one (R9) of 16 residents reviewed for environment on the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to hold regular resident council meetings. This failure had the potential to affect all 29 residents residing in the facility.