A list of the most recent deficiencies for Decatur Rehab and Health Care Ct. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-26 | 2024-02-22 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-08-22 | 2023-11-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-09 | 2023-09-26 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-22 | 2023-09-19 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-08-22 | 2023-09-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-22 | 2023-09-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-08-22 | 2023-09-14 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-08-22 | 2023-09-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-22 | 2023-09-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-22 | 2023-09-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-22 | 2023-09-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-22 | 2023-09-14 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-22 | 2023-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-22 | 2023-09-14 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-08-22 | 2023-09-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-22 | 2023-09-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-22 | 2023-09-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-22 | 2023-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-22 | 2023-09-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-22 | 2023-09-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-22 | 2023-09-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Develop a communication plan. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2023-08-09 | 2023-08-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-31 | 2023-08-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-31 | 2023-08-11 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-31 | 2023-08-11 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-07-31 | 2023-08-11 | Y |
| Keep all essential equipment working safely. | Health | 2023-07-31 | 2023-08-11 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-25 | 2023-06-09 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-05 | 2023-04-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-08 | 2023-03-24 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-08 | 2023-03-24 | Y |
| Post nurse staffing information every day. | Health | 2023-03-08 | 2023-03-24 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-22 | 2023-03-13 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-27 | 2022-12-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-27 | 2022-11-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-27 | 2022-11-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-27 | 2022-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-27 | 2022-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-09-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-27 | 2022-09-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-27 | 2022-09-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-07-27 | 2022-09-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-07-27 | 2022-09-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-27 | 2022-09-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-27 | 2022-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-27 | 2022-09-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-07-27 | 2022-09-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-27 | 2022-09-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-27 | 2022-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-27 | 2022-09-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-27 | 2022-09-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-27 | 2022-09-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-27 | 2022-09-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-07-27 | 2022-09-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-27 | 2022-09-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-27 | 2022-09-08 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-07-27 | 2022-09-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-27 | 2022-09-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-07-27 | 2022-09-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-27 | 2022-09-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-27 | 2022-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-27 | 2022-09-08 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-27 | 2022-09-08 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-07-27 | 2022-09-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Develop a communication plan. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-28 | 2022-09-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-11 | 2022-06-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-11 | 2022-06-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-11 | 2022-06-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-11 | 2022-06-03 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-11 | 2022-06-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-02 | 2022-03-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-02 | 2022-03-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-15 | 2021-12-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-16 | 2021-12-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-16 | 2021-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-16 | 2021-12-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-16 | 2021-12-07 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-11-16 | 2021-12-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-16 | 2021-12-07 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-16 | 2021-12-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-27 | 2021-11-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-27 | 2021-11-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-12 | 2021-10-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-05 | 2021-10-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-05 | 2021-10-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-05 | 2021-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-05 | 2021-10-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-05 | 2021-10-18 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-05 | 2021-10-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-29 | 2021-08-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-29 | 2021-08-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-29 | 2021-08-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-29 | 2021-08-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-29 | 2021-08-10 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-27 | 2021-07-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-27 | 2021-07-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-27 | 2021-07-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-06-25 | 2021-06-25 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-27 | 2021-06-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-28 | 2021-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-28 | 2021-06-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-05-28 | 2021-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-28 | 2021-06-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-28 | 2021-06-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Establish methods for sharing information. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-28 | 2021-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-28 | 2021-06-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-28 | 2021-06-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-28 | 2021-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-28 | 2021-06-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-28 | 2021-06-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-28 | 2021-06-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-14 | 2021-04-30 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-04-14 | 2021-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-14 | 2021-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-14 | 2021-04-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-09 | 2021-04-23 | Y |
