Decatur Health & Rehab Center

F-F658-Services Provided Meet Professional Standards.

The IJ began on 01/04/2025 and continued until 02/01/2025 when the facility implemented corrective action to remove the immediacy. On 02/02/2025 the immediate jeopardy was removed, F 658 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

This affected RI #497 one of six residents sampled for change in condition.

This deficiency was cited as the result of the investigation of complaint/report number AL00049932.

Findings include:

Cross-Reference F 580 and F 684.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 1.) RI #497 was admitted to the facility on [DATE REDACTED], with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Respiratory Disorders in Diseases, Essential Hypertension, Obstructive Sleep Apnea, and Level of Harm - Immediate Unspecified Atrial Fibrillation. jeopardy to resident health or safety RI #497's Admission Minimum Data Set assessment, with an Assessment Reference Date of 12/31/2024, identified RI #497 to score a 15 of 15 on the Brief Interview for Mental Status which indicated that RI #497 Residents Affected - Few had intact cognition.

RI #497's Weight and Vitals Summary flow sheet documented the following:

. Pulse Summary .

12/27/2024 19:57 (7:57 PM) 60 bpm .

12/28/2024 07:41 (7:41 AM) 76 bpm .

(12/29/2024 - 01/02/2025 No documented HRs) .

01/03/2025 14:01 (2:01 PM) 99 bpm .

01/03/2025 14:53 (2:53 PM) 99 bpm .

01/04/2025 13:24 (1:24 PM) 142 bpm (Irregular - chronic) .

01/04/2025 21:22 (9:22 PM) 120 bpm . No additional vital signs or pulse was documented.

The facility's physician orders for RI #497's revealed a verbal order dated 01/04/2025 at 1:57 PM for vital signs and to check RI #497's pulse manually twice per day. This order was created by Licensed Practical Nurse (LPN) #10.

On 01/31/2025 at 10:38 AM, an interview was conducted with LPN #10, the LPN assigned to care for RI #497 on 01/04/2025 on the 6 AM to 6 PM shift. LPN #10 said she reported RI #497's HR of 142 on 01/04/2025 at 1:24 PM to CRNP #15. LPN #10 said she did not see in RI #497's medical record that she reassessed RI #497's HR before she left. LPN #10 said not assessing RI #497 could put RI #497 at risk for a heart attack.

On 01/31/2025 at 5:10 PM, a follow-up interview was conducted with LPN #10. LPN #10 said she entered

the order for RI #497's HR to be checked twice a day to start at 8:00 PM. LPN #10 said she did not recall if

she notified her relief (LPN #16) of the need to obtain RI #497's HRs manually. When asked since she had another four hours on her shift did she feel she needed to check RI #497's HR before she left, LPN #10 said

she just put the order in for twice a day and the next HR check was for 8:00 PM. LPN #10 said she should have entered a progress note to inform the oncoming staff and others of RI #497's status, but did not. LPN #10 said the concern of not documenting in RI #497's progress notes about RI #497's care and HR was no one would know that a problem had occurred. LPN #10 said the concern of her not taking RI #497's HR after

the order was given was RI #497's HR could have gone up a lot more.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 On 01/30/2025 at 11:55 AM, an interview was conducted with CRNP #15. CRNP #15 confirmed that nursing staff had contacted her when RI #497 had a HR of 142. CRNP #15 said she instructed staff to assess the Level of Harm - Immediate resident, recheck the HR manually twice a day, and if the HR did not go lower to send RI #497 to the jeopardy to resident health or hospital. CRNP #15 said she did not know why RI #497 was not sent to the hospital until around 4:00 AM. safety

On 01/30/2025 at 6:30 PM, a follow-up interview was conducted with CRNP #15. CRNP #15 said there Residents Affected - Few should have been another assessment of RI #497's HR after she was informed of RI #497's HR was 142 and gave the order to check it manually twice a day.

On 01/30/2025 at 6:09 PM, a telephone interview was conducted with the Medical Director (MD). The MD said RI #497 should have been sent out for the HR of 142 if RI #497 was symptomatic.

RI #497's Progress Notes, dated 01/05/2025 at 12:36 AM, documented:

. Difficulty breathing noted. Nurse reported labored breathing . This note was written by LPN #16.

On 01/31/2025 at 5:49 PM, a telephone interview was conducted with LPN #16, the LPN providing care to RI #497 on 01/04/2025 on the 6 PM to 6 AM shift. LPN #16 said more than likely she assessed RI #497's HR

on 01/04/2025 at 9:22 PM, but she did not remember what was done for RI #497's elevated HR until he/she was sent to the ER.

The document titled [NAME] (Eastern Hospital Medicine) providerLink conversation which was initiated on 01/05/2025 at 3:51 AM by LPN #16 and sent to CRNP #30, documented the following:

. Chest pain. Dyspnea. Pulse 120-150. Can't breath. Copd. Sending to ER per resident request .

RI #497's Progress Notes dated 01/05/2025 at 4:10 AM electronically signed by LPN #16, revealed the following:

. Sent to (name of local hospital) per resident request . on call CRNP aware . Resident is dyspneic. Unable to catch (his/her) breath. Unable to talk. Pulse 120-150 .

2.) RI #497's Order Summary Report (Physicians Orders) revealed RI #497 had a Physicians Order for Digoxin Oral Tablet 125 MCG (micrograms) Give 125 mcg by mouth one time a day every other day. This order had a start date of 12/28/2024.

Davis's Drug Guide identifies Digoxin as a high-risk medication. The Guide includes assessment instructions to monitor apical pulse for one full min before administering and to hold the dose if pulse rate is less than 60 bpm in an adult.

A review of RI #497's December 2024 electronic Medication Administration Record (eMAR) revealed RN #14 administered RI #497's Digoxin at 8:00 AM on 12/30/2024. There was no evidence RI #497's HR had been checked before he/she received the Digoxin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 On 02/01/2025 at 5:52 PM, an interview with was conducted with RN #14 who said the standard of practice nurses use before administering Digoxin was to follow the doctor's orders. RN #14 said she did not check RI Level of Harm - Immediate #497's HR on 12/30/2024 because there were no doctor's orders to check the HR. RN #14 said there was no jeopardy to resident health or place to document the HR on the December 2024 eMAR. safety

A review of RI #497's January 2025 eMAR revealed LPN #28 administered RI #497's Digoxin at 8:00 AM on Residents Affected - Few 01/01/2025. There was no evidence RI #497's HR had been checked before he/she received the Digoxin.

On 02/02/2025 at 1:23 PM, a telephone interview was conducted with LPN #28, the LPN assigned to care of RI #497 on 01/01/2025. LPN #28 said the standard of practice nurses use before administering Digoxin was to check the apical pulse. LPN #28 said evidence she had checked RI #497's pulse on 01/01/2025 would be

on the January eMAR.

On 02/01/2025 at 4:55 PM, an interview was conducted with the Director of Nursing (DON). The DON said

the standard of practice for administering Digoxin was to administer medication as ordered. The DON said

the facility's protocol for assessing a resident's HR was done per doctor's order. When asked how would the staff know when to assess the HR of residents before administering Digoxin, the DON said it would be on the physician's orders and eMAR.

On 02/01/2025 at 3:33 PM, a telephone interview was conducted with the Medical Director (MD). The MD said it was standard of practice to check the HR of a person receiving Digoxin before administering the medication. The MD said if an order had not been written to check the heart rate before administering the Digoxin he would have written one, but it was just standard or practice for the nurse to assess resident's HR

before administering Digoxin.

A review of RI #497's Weight and Vitals Summary flow sheet and RI #497's Progress Notes revealed there was no evidence RI #497's HR had been checked on 12/30/2024 or on 01/01/2025 before RI #497 was administered the Digoxin.

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On 02/03/2025 the facility submitted an acceptable removal plan, which documented:

A. Immediate action(s) taken for the resident(s) found to have been potentially affected include:

1. 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 REDACTED] at 0410.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 3. The Director of Nursing (DON) provided 1:1 education to the licensed nurse that took the verbal order, and did not communicate to the oncoming nurse on 2-1-25. Education included completely and accurately Level of Harm - Immediate transcribing an order received from a physician or CRNP, following up on an order and communicating new jeopardy to resident health or orders to the oncoming nurse that require follow up, and assessing residents heart rate prior to administering safety digoxin.

Residents Affected - Few B. Identification of other residents having the potential to be affected:

1. This has the potential to affect all residents that reside in the facility on 2-1-25.

2. On 2-1-25, the DON reviewed all current in-house residents last recorded vital signs to identify any resident with vital signs outside the parameters set forth by the Medical Director. Any resident identified with vitals signs outside the parameters, the provider was notified, and any new orders as indicated.

3. All residents in house on Digoxin (and amiodarone, clonidine) were reviewed by the DON, Regional Director of Health Services (RDHS) and Pharmacist on 2-1-25 to ensure heart rate/blood pressure documentation was included on the Medication Administration Record with parameters for Digoxin (and amiodarone, clonidine). There were 13 residents reviewed. There were no other residents that did not have documentation of HR/BP on MAR.

4. Beginning on 02/01/2025, the nurse that transcribes the order will be responsible for ensuring HR/BP as indicated documentation is included for any residents with new digoxin (and amiodarone, clonidine) orders.

The clinical meeting (M-F) by the DON and Nurse Managers will verify HR/BP documentation will be included with any new Digoxin orders.

5. The process to ensure the MAR includes vital sign monitoring/parameters for ALL medications which require monitoring of vitals before administration per standards of practice will be:

i. On 02/01/2025 MD and Facility Pharmacist determined on 2-1-2025 the following medications require VS monitoring preadministration: Clonidine-hold if systolic BP <90 or diastolic BP <55 and notify MD/NP ; Amiodarone-hold if pulse < 55bpm or systolic BP <100 or diastolic BP <60 and notify MD/NP; Digoxin-hold if pulse <60bpm and notify MD/NP.

ii. The DON/ Regional Director of Health Services/ Facility Pharmacist completed an audit of residents' medications to ensure all medications with an established standard of practice to check vitals pre-administration are identified and the monitoring is included on the MAR. If residents. The audit was completed on 2-1-2025, there were 13 residents reviewed, and 8 residents required updates on the MAR. Specifically, we updated the VS parameters as set forth by the Medical Director on 2-1-25 for Digoxin, Clonidine and Amiodarone.

iii. During the clinical meeting (M-F) the DON and Nurse Managers will verify all new orders for medications requiring VS monitoring include the required monitoring and documentation on the MAR.

iv. The nurses will know the thresholds for VS, HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine because it was posted at the nurses station on 1-28-25 by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 C. Actions taken/systems to be put into place to reduce the risk of future occurrences include:

Level of Harm - Immediate 1. Vital Sign threshold alerts were updated to the electronic medical record for all residents by the DON and jeopardy to resident health or RDHS on 2-1-25. safety 2. The RDHS revised the New Admit/Readmit Checklist on 2-1-25 to include setting the vital sign parameter Residents Affected - Few thresholds set forth by the Medical Director and Pharmacist related to Clonidine, Amiodarone, and digoxin orders have heart rate and or BP parameters for monitoring, holding of medication and notification of MD/NP.

3. All licensed nurses (31 licensed nurses), were provided with education by the DON and Staff Development Coordinator on 2-1-25. Any licensed nurse who did not receive this education will not be allowed to work until

the education has been provided (there is 1 pending nurse on medical leave and the DON is responsible to ensure they are educated before working). Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents' heart rate and or BP prior to administering Clonidine, Amiodarone and Digoxin, the updated procedures 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 nurses were educated that the thresholds for VS was posted at

the nurses station on 1-28-25 by 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.

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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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47408 jeopardy to resident health or safety Based on interviews and resident record reviews the facility failed to ensure:

Residents Affected - Few 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 REDACTED] after being admitted to the hospital on 12/17/2024 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). The CRNP was notified and gave an order to send him/her to the hospital if his/her HR did not decrease. On 01/04/2025 at 9:22 PM RI #497's HR was 120 bpm. No action was taken until the RI #497 complained of chest pain, shortness of breath, and requested to be transferred to the hospital.

It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.25, Quality of Care.

On 02/01/2025 at 8:00 PM, the Administrator, the DON, the Executive [NAME] President of Operations, two Regional Director of Health Services nurses, the Regional Assessment Compliance Coordinator and the Chief Clinical and Regulatory Officer were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 684.

The IJ began on 01/04/2025 and continued until 02/01/2025 when the facility implemented corrective action to remove the immediacy. 02/02/2025 the immediate jeopardy was removed, F 684 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

This affected RI #497 one of six residents sampled for change in condition.

This deficiency was cited as the result of the investigation of complaint/report number AL00049932.

Findings include:

Cross-Reference F 580 and F 658.

RI #497's hospital DISCHARGE SUMMARY dated 12/27/2024 included REHAB ORDERS which documented that RI #497 was to have routine vital signs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 RI #497 was admitted to the facility on [DATE REDACTED] with diagnosis to include Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Essential Hypertension. Level of Harm - Immediate jeopardy to resident health or A review of RI #497's Order Summary Report revealed on 12/27/2025, an admission order was input for RI safety #497's vital signs to be checked once a month and as indicated. There were no parameters given at this time as to when the Physician or CRNP were to be notified when the resident's vital signs were out of normal Residents Affected - Few range.

A review of RI #497's Weights and Vitals Summary flow record indicated there was no evidence RI #497's vital signs were assessed on 12/29/2024, 12/30/2024, 12/31/2024, 01/01/2025, nor 01/02/2025, five of ten days RI #497 was a resident at the facility. RI #497's pulse was documented on 01/04/2025 at 1:24 PM as 142 bpm and on 01/04/2025 at 9:22 PM 120 bpm.

During an interview on 01/30/2025 at 6:29 PM with Registered Nurse (RN) #25, the nurse who entered RI #497's admission orders, RN #25 said the standard for checking vital signs on new admissions should be every shift until discharged .

An interview was conducted on 01/30/2025 at 10:46 AM with the RN/Unit Manager (UM) #8. She was asked how often vital signs were to be assessed for RI #497 and she stated as often as prescribed, per orders. She further stated that she entered an order on 01/03/2025 for vital signs every shift for blood pressure, heart rate, and oxygen sats every shift for three days.

On 01/30/2025 at 6:29 PM an interview was conducted with RN #25, House Supervisor. RN #25 reported that newly admitted residents should have vitals assessed each shift until discharged .

During an interview with the Director of Nursing (DON) on 01/30/2025 at 4:49 PM, the DON stated RI #497's orders were entered on 12/27/2024 for RI #497's vitals to be assessed once a month. The DON stated newly admitted residents should have vital signs assessed at least daily. The DON said there was no evidence that RI #497's vital signs were assessed from 12/29/2024 through 01/02/2025.

During an interview with CRNP #15 on 01/30/2025 at 1:15 PM the CRNP stated the standing order was for vital signs to be assessed each shift for newly admitted residents. CRNP #15 said vital signs were assessed once per month for long-term residents who were stable.

On 01/30/2025 the DON presented a Vital Signs Parameter guideline implemented on 01/28/2025, which was signed by the Medical Director (MD). The parameter for the Pulse indicated a pulse of 110 was considered High. Documented on the form were instructions to Please call MD (Medical Director)/NP (Nurse Practitioner) when vital signs are out of parameters.

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On 02/03/2025 the facility submitted an acceptable removal plan, which documented:

1. Immediate action(s) taken for the resident(s) found to have been potentially affected to include:

A. The facility failed to ensure:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 1) A system was in place to ensure newly admitted residents vital signs were assessed at a frequency expected by the physician/CRNP. Level of Harm - Immediate jeopardy to resident health or 2) Resident specific vital sign parameters were established including when the physician should be notified safety of abnormal values.

Residents Affected - Few B. The Director of Nursing contacted the Medical Director on 01-28-25 for guidance on updating vital sign thresholds for notification.

C. On 2-1-25, the Medical Director was contacted by the DON on his expectations on vital sign monitoring.

2. Identification of other residents having the potential to be affected:

A. All newly admitted residents have the potential to be affected

B. The Regional Director of Health Services (RDHS), Director of Nursing (DON), and Regional Assessment Coordinator reviewed all vital signs on all residents newly admitted to the facility in the last 30 days had an order to monitor vital signs per the Medical Directors expectations. This was completed on 2-1-25.

3. Actions taken/systems to be put into place to reduce the risk of future occurrences include:

A. An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission. Completed on 2-1-25.

B. The vital sign monitoring policy was updated on 2-1-25 by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks. The changes to the VS Monitoring Policy were based

on discussion and recommendation of The Medical Director on 2-1-2025.

C. The Director of Nursing contacted the Medical Director on 1-28-25 for guidance on updating vital sign thresholds for notification.

D. On 2-1-25, the Medical Director was contacted by the DON on his expectations on vital sign frequency.

E. Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders on 2-1-25 by the RDHS and DON. The facility parameters were discussed with The Medical Director on 2-1-2025 and were updated. In addition, it was noted by The Medical Director that there will be residents that may require specific parameters based on clinical need.

F. The Daily Clinical Meeting form was revised on 2-1-25 by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 G. The DON and Staff Development Coordinator on 2-1-2025 provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an Level of Harm - Immediate admission or re-admission and vital signs thresholds that require physician notification, and process to jeopardy to resident health or document vitals, notification, and physician recommendations. safety

The facility requests for the IJ removal plan to be effective on 2-2-25. This plan was written by the Executive Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 20304

Residents Affected - Many Based 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.

Findings include:

The U.S. FDA 2022 Food Code included the following:

. 3-501.13 Thawing.

. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:

(A) Under refrigeration that maintains the FOOD temperature at 5 [degrees] C [Centigrade/Celsius] (41 F [Fahrenheit]) or less .; or

(B) Completely submerged under running water:

(1) At a water temperature of 21 C (70 F) or below .,

(2) With sufficient water velocity to agitate and float off loose particles in an overflow ., and

(3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 C (41 F) ., or

(4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking . to be above 5 C (41 F), for more than 4 hours including:

(a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking ., or

(b) The time it takes under refrigeration to lower the FOOD temperature to 5 C (41 F) .;

(C) As part of a cooking process if the FOOD that is frozen is:

(1) Cooked . or

(2) Thawed in a microwave oven and immediately transferred to conventional cooking EQUIPMENT, with no interruption in the process .

3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 (A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or Level of Harm - Minimal harm or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a potential for actual harm temperature of 5 [degrees] C [Centigrade/Celsius] (41 F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Residents Affected - Many

The facility's policy for Food Safety Requirements, dated 09/01/2024, included the following:

. Policy: . Food will also be stored, prepared, . in accordance with professional standards for food safety.

Policy Explanation and Compliance Guidelines:

1. Food safety practices shall be followed throughout the facility's entire food handling process. Elements of

the process include the following: .

b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.

c. Preparation of food, including thawing, .

3. Facility staff shall . ensure timely and proper storage.

c. Refrigerated storage .

iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or . discarded .

4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards.

a. Thawing - approved methods for thawing frozen foods include thawing in the refrigerator, submerging under cold water, thawing in a microwave oven, or as part of a continuous cooking process. Thawing at room temperature is not acceptable.

The facility's policy for Date Marking for Food Safety, dated 09/01/2024, included the following:

. Policy:

The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food.

Definitions:

'Time/temperature control for safety food' (formerly potentially hazardous food) includes an animal food that is raw or heat-treated, .

Policy Explanation and Compliance Guidelines for Staffing:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 days. Level of Harm - Minimal harm or potential for actual harm 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Residents Affected - Many

During the initial kitchen observation on 01/27/2025 at 5:14 PM, clear plastic bags of chicken were observed

in a prep (preparation) sink while staff were engaged in the residents' supper trayline. At 5:55 PM, during the initial tour with the Dietary Manager, three clear plastic bags of frozen chicken pieces were observed defrosting in the Meat Prep Sink. There was no water in the sink, no water running, and the bags of chicken were not in any container to be submerged in water. The supper menu for 01/27/2025 did not include chicken.

At 6:10 PM on 01/27/2025, while touring the kitchen with the Dietary manager, two boiled eggs were observed in a plastic container without a use-by date in the Reach-in Cooler.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 20304 potential for actual harm Based on observation, interview, the facility's policy for Disposal of Garbage and Refuse, and the United Residents Affected - Many 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.

Findings include:

The U.S. FDA 2022 Food Code included the following:

. 5-501.15 Outside Receptacles.

(A) Receptacles and waste handling units for REFUSE, . with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

(B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around . the unit.

5-501.113 Covering Receptacles.

Receptacles and waste handling units for REFUSE, . shall be kept covered: .

(B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.

5-501.115 Maintaining Refuse Areas and Enclosures.

A storage area and enclosure for REFUSE, . shall be . clean.

The facility's policy for Disposal of Garbage and Refuse, dated 09/01/2024, included the following:

. Policy:

The facility shall properly dispose of kitchen garbage and refuse.

Policy Explanation and Compliance Guidelines: .

7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 10. Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at

a frequency necessary to prevent them from . becoming attractants for insects and rodents. Level of Harm - Minimal harm or potential for actual harm During the initial kitchen tour with the Dietary Manager on 01/27/2025 at 5:31 PM, the outside Dumpster Area was observed. There were two dumpsters, one dumpster with a side door left open and the other Residents Affected - Many dumpster with a broken lid. In addition, food-related trash was observed on the ground around the dumpster area. The observed food-related trash included two plastic spoons, one plastic knife, one food container with

a lid, two condiment packages, four straws, more than six gloves, one empty juice cup, two cup lids, and additional items. Upon being asked the concern with the dumpsters 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39580

Residents Affected - Few Based 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.

Findings include:

A facility policy titled Documentation in Medical Record with a review date of 12/31/2024, documented:

. Policy Explanation and Compliance Guidelines .

4. Principles of documentation include, .

a. Documentation shall be factual, objective .

i. False information shall not be documented .

b. Documentation shall be accurate, relevant, and complete .

RI #447 was admitted to the facility on [DATE REDACTED] with diagnoses to include Diabetes Mellitus with Hyperglycemia.

RI #447's nursing note dated 11/02/2024 at 9:34 AM signed by LPN #27 documented: . Lantus was not given

this AM. I mistakenly charted that the insulin was given.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 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 Level of Harm - Minimal harm or document the medication as not administered and the reason. The DON said, the potential concern of not potential for actual harm following the facility's policy on documentation was an inaccurate record of treatment.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21055 potential for actual harm Based on observations, interviews, and review of a facility policy titled Infection Prevention and Control Residents Affected - Few 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.

Finding include:

Review of a facility policy titled, Infection Prevention and Control Program, 09/01/2024, revealed the following:

Policy:

This facility has established and maintains 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 as per accepted national standards and guidelines.

Policy Explanation and Compliance Guidelines: .

2. All staff are responsible for following all policies and procedures related to the program.

4. Standard Precautions:

a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.

10. Equipment Protocol:

a. All reusable items and equipment requiring . disinfection . shall be cleaned in accordance with our current procedures governing the cleaning . of . contaminated equipment.

RI #61 was admitted to the facility on [DATE REDACTED].

RI #70 was admitted to the facility on [DATE REDACTED].

On 01/29/2025 at 10:55 AM LPN #20 was observed preparing medications for administration to RI #61. LPN #20 punched pills from two bubble pack medication cards into his bare hands, placed the pills into a medication cup, and then administered the medication to RI #61 by mouth.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 01/29/2025 at 11:23 AM LPN #20 placed a blood pressure cuff, pulse oximeter, and thermometer on the bed of a resident, used the medical equipment to check the resident's vital signs, then placed the medical Level of Harm - Minimal harm or equipment on top of the medication cart. potential for actual harm

On 01/29/2025 at 11:52 AM LPN #20 used the medical equipment, that had not been cleaned or disinfected, Residents Affected - Few from the top of the medication cart to assess RI #70's vital signs. After assessing RI #70's vital signs, LPN #20 placed the medical equipment back on top of the medication cart without cleaning or disinfecting the equipment.

On 01/29/2025 at 12:09 PM LPN #20 was asked about administering medications. LPN #20 said, he 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 20304 potential for actual harm Based on observation, interview, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Residents Affected - Many 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.

Findings include:

The U.S. FDA 2022 Food Code included the following:

. 4-501.11 Good Repair and Proper Adjustment.

(A) EQUIPMENT shall be maintained in a state of repair .

During the initial kitchen tour on 01/27/2025 at 5:51 PM, the Dietary Manager revealed the Tilt Skillet had been out of order for about four years and it was currently being used as a countertop. The Double Steamer was also found to be out of order. The Dietary Manager said it had stopped working in 2023. At 6:14 PM, the Dietary Manager said the two Stove Ovens (below the Stovetop and Griddle) can work, but the pilot lights go out when the doors are shut.

The Maintenance Director was interviewed on 01/29/2025 at 3:32 PM. When asked about the Tilt Skillet, the Maintenance Director said the previous company owning the facility was told it was going to be cheaper to replace it than to fix it. The Maintenance Director further said the new company owning the facility just had a guy come in to look at it (Tilt Skillet) and he told them the same thing, it was going to be cheaper to replace than to fix. The Maintenance Director was unsure how long the Tilt Skillet had been broken, but he knew it had been more than a year. The Maintenance Director said the Double Steamer was in the same category as the Tilt Skillet. He said the problem was water dripping down from the Steamer's tank onto the gas flames beneath. The Maintenance Director further said the repair person brought in today by the new company owner had said it would be best to get a new one (Double Steamer). The Maintenance Director said he had been asked several times to light the pilots of the Stove Ovens, but the ovens work fine. The Maintenance Director said staff was using fans to dry the floor quickly and that would blow out the oven pilot lights. The Maintenance Director said he reported major equipment issues to the corporate office for a decision, because of the money involved. The Maintenance Director further said the change in management meant some things had fallen through the cracks. When asked the problem with having broken, major cooking equipment unrepaired for long periods of time, the Maintenance Director said cooking could be delayed, by having back-up equipment the risk was less. If there were two pieces of equipment and one went down, they would have a back-up. If both went down, they would have a problem.

The Dietary Manager was interviewed on 01/29/2025 at 4:13 PM. When asked the problem with having broken, major cooking equipment going unrepaired for long periods of time, the Dietary Manager said they would not have anything to cook off of if other equipment went down.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 015206 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 The Registered Dietitian (RD) was interviewed on 01/29/2025 at 4:24 PM. When asked the problem with having broken, major cooking equipment going unrepaired for long periods of time, the RD said inadequate Level of Harm - Minimal harm or equipment for preparing food for the residents. potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 015206