Decatur Rehab & Health Care Ct

In the surveyor’s words

From the most serious findings on record at Decatur Rehab & Health Care Ct, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610Oct 27, 2022

  Based on observation, interview, and record review the facility failed to investigate repeated allegations of sexual and physical abuse of R1 by an employee and failed to prevent potential further abuse by failing to remove the alleged perpetrator (V4, Registered Nurse) from direct resident care for one (R1) of six residents reviewed for sexual abuse on the sample list of seven. These failures resulted in the alleged perpetrator having direct contact with R1 for ten more days in a two-week time period. During this time R1 continued to make daily allegations of physical and sexual abuse against V4, was scared for her safety, was unable to sleep, and felt like no one was listening to her. This failure had the potential to affect all 36 residents residing in the facility. […]

• Immediate jeopardy, isolatedF600Oct 5, 2021

  Based on interview and record review, the facility failed to supervise residents (R1 and R2) with a known history of inappropriate sexual behavior to prevent resident to resident sexual abuse. This failure resulted in R2 being sexually abused by R1. Staff allowed R1 and R2 to go unsupervised with unrestricted access to each other resulting in sexual behaviors between two residents who are unable to consent, exposing them to abuse. This failure affects two (R1, R2) of residents reviewed for abuse in the sample list of 12 residents. This failure resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF686Sep 25, 2024

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

• Actual harm, isolatedF684Apr 4, 2024

  Based on interview and record review the facility failed to provide pain control and failed to transfer a resident with a broken femur to the hospital in a timely manner for one (R1) of three residents reviewed for falls in the sample list of three. This failure resulted in R1 remaining in the facility for ten hours while in pain with a broken left femur before being transferred to the hospital for pain control and care. Findings include: R1's diagnoses include: Alzheimer's Disease, Dementia, Gastroesophageal Reflux Disease, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Pulmonary Disease, Hypothyroidism, Atherosclerosis, Heart Disease, Hypertension, Anxiety Disorder, Cardiomyopathy, Left Hip Replacement, Anemia, Vitamin D Deficiency, Right Eye… […]

• Actual harm, isolatedF689Apr 4, 2024

  Based on interview and record review the facility failed to implement effective interventions to prevent falls with injury for one (R1) of three residents reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a fractured left hip. Findings include: R1's diagnoses include: Alzheimer's Disease, Dementia, Gastroesophageal Reflux Disease, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Pulmonary Disease, Hypothyroidism, Atherosclerosis, Heart Disease, Hypertension, Anxiety Disorder, Cardiomyopathy, Left Hip Replacement, Anemia, Vitamin D Deficiency, Right Eye Blindness, Periodontal Disease, Falls, Nicotine Dependence and a History of Alcohol Abuse. […]