Decatur Wellness and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Decatur Wellness and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 12, 2022

  Based on review of facility policy, medical record review, review of the facility investigation, observations, review of facility floorplan, review of National Oceanic and Atmospheric Administration (NOAA) weather data, and interview, the facility failed to secure windows in the common dining area which resulted in the elopement of 1 resident (Resident #1) of 6 residents reviewed for elopement risk or accidents. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death) when Resident #1 opened an unsecured window in the common dining area, exited to the outside, and fell to the ground. […]

• Immediate jeopardy, isolatedF689Jun 25, 2021

  Based on review of facility policies, medical record review, review of facility investigations, observations, and interviews, the facility failed to utilize safe transfer techniques for 3 residents (Resident #1, Resident #3, and Resident #5) of 7 residents reviewed for transfers, resulting in Residents #1, #3, and #5 sustaining falls. Resident #1 was being transferred with a mechanical lift by Certified Nursing Assistant (CNA) #1 and #2 when CNA #2 left the room and CNA #1 completed the 2-person transfer alone, resulting in the mechanical lift tipping over. Resident #1 was dropped to the floor and sustained facial swelling. Resident #3 required a mechanical lift for all transfers. […]

• Immediate jeopardy, isolatedF726Jun 25, 2021

  Based on review of facility policies, medical record review, review of facility investigation, interviews, and review of employee personnel files, the facility failed to ensure staff were adequately trained and could demonstrate the job skills necessary to provide safe transfers using a mechanical lift for 3 residents (Resident #1, Resident #3, and Resident #5) of 7 residents reviewed for transfers, resulting in Residents #1, #3, and #5 sustaining falls. The facility's failure placed Resident #1, Resident #3, and Resident #5 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). […]

• Actual harm, isolatedF600May 12, 2022

  Based on review of facility policy, medical record reviews, review of the facility investigation, and interviews, the facility failed to prevent resident abuse for 1 resident (Resident #2) of 6 residents reviewed for abuse or neglect. Resident #1 struck Resident #2 in the face with a closed fist on the morning of 5/5/22, which caused Resident #2 psychosocial harm. The findings included: Review of the facility policy, Abuse, Neglect and Exploitation revealed .policy of this facility is to provide protections .that prohibit abuse .includes but is not limited to hitting, slapping, punching . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jun 9, 2021

  Based on observation and interview, the facility failed to timely repair an air condition ventilation system in 1 of 1 dietary department to prevent water from dripping onto the kitchen ceiling and drywall in the walk in cooler and dry storage area. The findings included: Observation of the dietary department on 6/9/2021 between 1:00 and 1:20 PM showed drywall damage and yellow stains on the ceiling above the walk-in cooler unit. Continued observations inside the dry storage area adjacent to the walk-cooler showed drywall damage and yellow stains extending inside the room around the air conditioning ventilation system located in the front corner of the dry storage area. […]