Inspection Report

Decatur Health & Rehab: Immediate Jeopardy Citation AL

October 31, 2025

Decatur, AL

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DECATUR, AL - Federal inspectors have cited Decatur Health & Rehab Center for immediate jeopardy violations after discovering serious failures in cardiac monitoring and medication administration protocols that potentially endangered resident safety.

Critical Cardiac Monitoring Failures

The most serious violations occurred when nursing staff documented dangerous heart rate irregularities in a resident with chronic obstructive pulmonary disease and atrial fibrillation but failed to follow through with appropriate medical protocols. On January 4, 2025, the resident's heart rate spiked to 142 beats per minute at 1:24 PM - well above the facility's threshold of 110 bpm requiring physician notification.

Licensed Practical Nurse #10, who was caring for the resident during the day shift, contacted the facility's nurse practitioner about the elevated heart rate. The nurse practitioner provided clear instructions: manually check the resident's pulse twice daily and send the resident to the hospital if the heart rate did not decrease. However, the nurse failed to reassess the resident's heart rate before ending her shift at 6 PM, despite having four additional hours to monitor this critical vital sign.

The order to check pulses manually was entered to begin at 8:00 PM, but the day shift nurse did not communicate this important information to the incoming evening nurse. At 9:22 PM, the resident's heart rate was documented at 120 bpm - still dangerously elevated but showing some improvement. No action was taken at this time.

The resident was not transferred to the emergency room until 4:10 AM the following morning, when he complained of chest pain and difficulty breathing. By this time, his pulse had increased to between 120-150 beats per minute, and he was experiencing significant respiratory distress.

Dangerous Medication Administration Practices

Inspectors also discovered serious violations in the administration of digoxin, a high-risk cardiac medication that requires careful monitoring. Digoxin is prescribed to regulate heart rhythm and strengthen heart contractions, but it can become toxic if not properly monitored. Standard medical practice requires checking a patient's heart rate before each dose, as the medication should be withheld if the pulse drops below 60 beats per minute.

On December 30, 2024, and January 1, 2025, nursing staff administered digoxin to the same resident without checking his heart rate beforehand. When questioned about this practice, one nurse stated she followed "doctor's orders" and claimed there was no specific order to check the heart rate. Another nurse acknowledged that checking the pulse before giving digoxin was standard practice but said evidence would be documented on the medication record - which showed no such documentation.

The facility's Medical Director confirmed that checking heart rate before administering digoxin is standard medical practice, regardless of whether a specific order exists. The Director of Nursing initially stated that staff should only assess heart rates when ordered by physicians, demonstrating a fundamental misunderstanding of medication safety protocols.

Medical Significance of Cardiac Monitoring Failures

Heart rate monitoring is particularly critical for residents with atrial fibrillation, a condition where the heart's upper chambers beat irregularly and often rapidly. When combined with chronic obstructive pulmonary disease, elevated heart rates can quickly lead to cardiovascular emergencies and respiratory failure.

A heart rate of 142 beats per minute in a resident with these conditions represents a significant cardiac stress that requires immediate attention. Prolonged periods of rapid heart rate can lead to heart failure, stroke, or cardiac arrest. The facility's failure to properly monitor and respond to these warning signs created a substantial risk of serious injury or death.

Digoxin toxicity represents another serious concern when proper monitoring protocols are not followed. This medication has a narrow therapeutic window, meaning the difference between an effective dose and a toxic dose is small. Without proper heart rate monitoring, residents can develop dangerous complications including severe bradycardia (slow heart rate), heart block, or potentially fatal arrhythmias.

Systemic Vital Signs Monitoring Problems

The inspection revealed broader issues with the facility's approach to vital signs monitoring for newly admitted residents. The resident at the center of these violations was admitted after a hospital stay for atrial fibrillation with rapid ventricular response, yet his vital signs were only ordered to be checked monthly rather than daily as expected for a new admission.

Multiple nurses confirmed that newly admitted residents should have vital signs assessed at least daily, with some stating it should occur every shift until the resident is stable. However, the facility's actual orders called for monthly assessments, and there was no evidence that vital signs were taken for five consecutive days following admission.

The facility also lacked proper parameters for when physicians should be notified of abnormal vital signs. It was not until January 28, 2025 - well after this incident - that the facility implemented guidelines specifying that pulses above 110 beats per minute required physician notification.

Additional Issues Identified

Inspectors documented several other concerning practices during their visit:

Food Safety Violations: Kitchen staff were improperly thawing frozen chicken by leaving it in a prep sink without running water, violating safe food handling protocols. Additionally, boiled eggs were stored without proper date marking, making it impossible to determine their safety for consumption.

Waste Management Problems: The facility's dumpster area had multiple issues including broken lids, open doors, and food-related trash scattered on the ground, creating conditions that could attract rodents and pests.

Infection Control Lapses: A licensed practical nurse was observed handling medications with bare hands and using vital signs equipment on multiple residents without proper cleaning and disinfection between uses.

Medical Records Accuracy: Staff incorrectly documented medication administration, with one nurse admitting she marked insulin as given when it was actually withheld, creating inaccurate treatment records.

Equipment Maintenance: Major kitchen equipment including a tilt skillet and double steamer had been non-functional for years, with some equipment reportedly broken for over four years.

The combination of these violations, particularly the immediate jeopardy findings related to cardiac monitoring, demonstrates systemic failures in the facility's clinical care and safety protocols. The immediate jeopardy status was removed on February 2, 2025, after the facility implemented corrective measures including staff education, updated policies, and enhanced monitoring procedures.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Decatur Health & Rehab Center from 2025-02-03 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 29, 2026 · Our methodology

Quick Answer

DECATUR HEALTH & REHAB CENTER in DECATUR, AL was cited for immediate jeopardy violations during a health inspection on February 3, 2025.

Licensed Practical Nurse #10, who was caring for the resident during the day shift, contacted the facility's nurse practitioner about the elevated heart rate.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at DECATUR HEALTH & REHAB CENTER?

Licensed Practical Nurse #10, who was caring for the resident during the day shift, contacted the facility's nurse practitioner about the elevated heart rate.

How serious are these violations?

These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in DECATUR, AL, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from DECATUR HEALTH & REHAB CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 015206.

Has this facility had violations before?

To check DECATUR HEALTH & REHAB CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.