Decatur Health & Rehab Center
DECATUR HEALTH & REHAB CENTER in DECATUR, AL — inspection on February 3, 2025.
Found 12 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
in condition, to include vital signs outside the parameters given on 2-1-25 by the DON and Staff
jeopardy to resident health or allowed to work until the in-service has been provided.
There is 1 LPN pending (on medical leave) and safety the DON is responsible to ensure they are educated before working
After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/02/2025.
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Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
that there were no residents with any unknown skin issues found.
disrespectfully or providing undignified care.
Staff were all asked if they understood how to handle
This was started on 8/24/24 and will be completed before returning to work.
C.) All residents on the 100-hall interviewed regarding care being provided, dignity, respect shown by the staff.
Any negative feedback or allegations will be addressed and investigated immediately.
This was started and completed on 8/24/24.
System change identified & education plan:
- A.) Staff re-educated by DON/Designee, began on 8/24/24 review resident's rights, dignity and
customer service regarding dealing with combative residents, dealing with stressful work environment, restraint policy, abuse not forcing care when a resident refuses care & review of the Abuse Policy.
This was started on 8/24/24 and was completed on 08/25/24.
Monitoring system:
- A.) Resident council will be questioned monthly regarding staff adherence to resident's rights, treating
all residents with dignity and in a respectful manner, allowing residents to make decisions with their care. An emergency meeting was held on 8/26/24 B.) Resident and staff will be questioned resident rights to a dignified existence, selfdetermination, protecting residents, abuse reporting and the use of restraints. 5 employees and 5 residents will be interviewed on the above 3 x week x 4 weeks, 5 employees and 5 residents will be interviewed on the above 1 x week x 4 weeks, then during the monthly inservice.
C.) An emergency QAPI meeting was conducted on 8/24/24 to review plan of action and progress.
Facility in compliance as of 8/25/24 with all reeducation and interviews. ********************* After review and verification of the information provided in the facility's corrective action plan, inservice/education records, monitoring tools, and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 08/23/2024 through 08/26/2024 with ongoing monitoring implemented; thus, past noncompliance was cited.
015206 02/03/2025
Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
Review of RI #497's Daily Progress Note, by CRNP #18, dated 12/31/2024, documented the following: .
Assessment/Plan . COPD Continuous O2 at 2L NC .
Review of RI #497's Daily Progress Note, by CRNP #15, dated 01/01/2025, documented the following: . He/She is resting quietly in his/her room .
Assessment/Plan . COPD: Continuous O2 at 2L NC .
Review of RI #497's Daily Progress Note by CRNP #15, dated 01/02/2025, documented the following: .
Assessment/Plan . COPD: Continuous O2 at 2L NC .
During an interview with Registered Nursed (RN), Unit Manager (UM) #8 on 01/30/2025 at 10:46 AM, she stated RI #497 was admitted from the hospital with an order for oxygen but, did not see an order on that date. RN #8 was asked who was responsible for transcribing the order.
She further stated the orders go through medical records and they transcribe them, but the admitting nurse was responsible for reviewing the orders to ensure all admission orders are transcribed. RN #8 said the order was not entered until on 01/03/2025.
During an interview with CRNP #18 on 01/30/2025 at 12:35 PM, she was asked upon her assessment of RI #497 on 12/28/2024 she documented that resident was short of breath on room air and she applied oxygen.
She said resident did not have oxygen applied and she applied oxygen to RI #497.
CRNP #18 was asked if there was an order for oxygen at the time she placed the oxygen on the resident. CRNP #18, said no.
Surveyor stated according to RI #497 medical record the order for oxygen was not transcribed until 01/03/2025, what would be the concern. CRNP #18 said, she had educated them (nurses) that oxygen was a medication that required an order.
An interview was conducted with the Director of Nursing (DON) on 01/30/2025 at 4:49 PM and she was asked who was responsible for ensuring the oxygen order was transcribed for RI #497.
The DON said the admitting nurse should have verified the orders from the hospital and the admitting nurse was RN #25.
The DON said she did not see an order for RI #497's oxygen use on 12/28/2024.
An interview was conducted with RN #25 on 01/30/2025 at 6:29 PM. RN #25 was asked what was the admission order for oxygen for RI #497. RN #25 stated, she/he needed to keep oxygen sats (saturation) at 88% or greater. RN #25 stated she was responsible for putting the admission order in but did not review the orders to see if the oxygen was transcribed into the facility's orders.
When asked what was the concern with not implementing the oxygen orders, she stated it would not have been on the Medication Administration Record (MAR) for staff to apply and the resident might have became hypoxic.
During an interview with Medical Director (MD) on 01/30/2025 at 6:09 PM, he was asked if RI #497 should have had orders put in the system for oxygen use on admission. He replied yes, RI #497 should have had a facility order upon admission for his/her oxygen use.
015206 02/03/2025
Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, revealed the following: CHAPTER 5: SUBMISSION .OF THE MDS ASSESSMENTS Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information.
Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. .
Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days).
All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) .
Resident Identifier (RI) #38 was admitted to the facility on [DATE] with diagnoses to include Type 2 diabetes mellitus without complications. RI #38 was discharged on 10/15/2024.
An interview was conducted with the Minimum Data Set Coordinator (MDS-C) on January 29, 2025, at 3:12 PM.
The MDS-C indicated that the MDS for RI #38, with an Assessment Reference Date (ARD) of October 15, 2024, was not submitted to the Centers for Medicare & Medicaid Services (CMS) within the required fourteen-day period following its completion.
She noted that the MDS was ultimately submitted on January 29, 2025, by the Regional Assessment Compliance Coordinator due to the oversight.
The MDS-C said the MDS should have been submitted within fourteen days after the ARD to ensure proper reporting to CMS.
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Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
and accurately transcribing an order received from a physician or CRNP, following up on an order and
jeopardy to resident health or heart rate and or BP prior to administering Clonidine, Amiodarone and Digoxin, the updated procedures safety including entering the order for assessment and documentation of HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine.
The
DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters.
The facility requests for the IJ removal plan to be effective on 2-2-25.
This plan was written by the Executive VP of Operations and the Regional Director of Health Services. ************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/02/2025.
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Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
as well as staff interviews, and observations, the survey team determined the facility implemented
jeopardy to resident health or safety
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Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
During an interview on 01/29/2025 at 4:02 PM, the Assistant Dietary Manager was asked why the frozen chicken was in the Meat Prep Sink on Monday evening (01/27/2025).
The Assistant Dietary Manager said that is where we put the frozen meat when transferring it from the Freezer to the Cooler, to try to thaw it a little bit.
The Assistant Dietary Manager further said we leave it in there about an hour and a half to get a head start on defrosting, before placing the bags in the Cooler.
The Dietary Manager was interviewed on 01/29/2025 at 4:13 PM.
When asked why the frozen chicken was in the Meat Prep Sink on Monday evening (01/27/2025), the Dietary Manager said I had just pulled it out of the Freezer when someone said State was in the building.
Upon being asked how the frozen chicken should have been thawed, the Dietary Manager said underneath water with the water running or else in the Cooler.
When asked about the two hard boiled eggs in the Reach-in Cooler seen on Monday evening (1/27/2025), the Dietary Manager said I think the AM [NAME] was going to use them in a salad, but she did not.
When asked the concern with the two hard boiled eggs not having a use-by date, the Dietary Manager said it could be potentially dangerous.
The Dietary Manager further said it could be potentially harmful to our residents because, without a date, you do not know how long it has been there and there is a potential for Food Borne Illness.
The Registered Dietitian (RD) was interviewed on 01/29/2025 at 4:24 PM.
The RD said the concern with the frozen chicken was that it was not being properly thawed; so Time/Temperature Control would be the problem and it could lead to Food Borne Illness, if it sat out too long in the Temperature Danger Zone.
The RD also said the lack of a use-by date meant there was no way to prove how long the two boiled eggs had been in the Reach-in Cooler.
015206 02/03/2025
Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
Dumpster Area was observed.
There were two dumpsters, one dumpster with a side door left open
knife, one food container with a lid, two condiment packages, four straws, more than six gloves, one
being open and the food related trash on the ground, the Dietary Manager said it could attract rodents.
When asked the potential danger to the residents, the Dietary Manager said the rodents could get into the facility.
The Registered Dietitian (RD) was interviewed on 01/29/2025 at 4:24 PM.
When asked the concern with one dumpster having a side door open, the other dumpster having a broken lid, and food related trash strewn around on the ground of the dumpster area; the RD said it can attract pests and rodents.
Upon being asked how this could affect the residents, the RD said pests and rodents could potentially enter the facility's kitchen.
015206 02/03/2025
Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
Review of RI #447's November 2024 Medication Administration Record revealed an entry on 11/02/2024 at 8:00 AM for which LPN #27 initialed as having administered Lantus Insulin to RI #447 at that time.
On 01/29/2025 at 08:52 AM an interview was conducted with LPN #27 and she was asked about RI #447's insulin administration for 11/02/2024. LPN #27 stated, she did not give the insulin RI #447 on 11//02/2024 because RI #447 was not eating or drinking. LPN #27 said, she accidentally hit the wrong key when she documented. LPN #27 said, she should have hit the key indicating the insulin was not required at that time. LPN #27 stated, if the medication was not documented accurately the MAR would not be complete and accurate. LPN #27 said, she did not follow facility policy for documentation.
On 01/29/2025 at 10:13 AM the Director of Nursing (DON) was asked about the facility's policy on documentation of a medication.
The DON stated, staff did not administer a medication, the staff would document the medication as not administered and the reason.
The DON said, the potential concern of not following the facility's policy on documentation was an inaccurate record of treatment.
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Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
disinfected, from the top of the medication cart to assess RI #70's vital signs.
After assessing RI
normally wore gloves when punching pills but had not worn gloves when preparing medications for RI #61. LPN #20 said, the concern with touching a resident's medications with his bare hands was infection control. LPN #20 said, he should have placed the medication card over the medication cup and allowed the pill to drop into the cup. LPN #20 was asked what was the concern when he placed the blood pressure cuff, the pulse oximeter, and the thermometer on a resident's bed. LPN #20 said, infection control. LPN #20 said, he should have placed the medical equipment on a barrier. LPN #20 was asked what was the concern when he placed the medical equipment back to the medication cart.
LPN #20 said, infection control. LPN #20 was asked what should he have done with the medical equipment before using it with another resident. LPN #20 said, he should have sanitized it.
On 01/31/2025 at 11:32 AM, an interview was conducted with the Director of Nursing (DON).
The DON said when pills are removed from the bubble pack, they should be placed over the medication cup and popped into the cup.
The DON said medications should not be touched with the bare hand.
The DON said when medical equipment is taken into a resident's room it was not ok to place the equipment on the bed.
The DON said the medical equipment should be placed on a barrier.
The DON said when medical equipment is used, and brought out of a resident's room, the equipment should be sanitized and allowed to air dry before being used again.
The DON said, medical equipment should never be taken out of a resident's room and placed on the medication cart without sanitizing it and letting it air dry.
The DON said when these things are not done there were concerns for contamination.
On 02/02/2025 at 6:31 PM a telephone interview was conducted with the Registered Nurse (RN)/Infection Preventionist (IP).
The IP said, the bubble pack should be held over the medication cup when pressing out the pill and pill should not be touched with bare hands.
The IP said, staff touching medications with their bare hands would be an infection control concern.
The IP said, at no time should staff place medical equipment on a resident's bed.
The IP said, there was no way to know what was on a bed and placing medical equipment on a resident's bed was not sanitary.
inadequate equipment for preparing food for the residents.
015206 02/03/2025
Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
The facility failed to ensure licensed staff followed standards of practice and completely and accurately transcribed an order received from a CRNP to send RI#497 to the emergency room if heart rate did not go down.
The nurse also did not communicate the order to the oncoming nurse.
The nurse further failed to re-assess RI #497's heart rate at the time the order was provided to ensure RI#497 did not need to be transferred to the ER.
The facility further failed to ensure process was in place to ensure resident's HR was checked prior to administration of digoxin.
2. RI #497 was transferred to theER on [DATE] at 0410.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 015206 B.
Wing 02/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Decatur Health & Rehab Center 2326 Morgan Avenue Southwest Decatur, AL 35603
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.