Inspection Report
Deficiencies: 0
Jun 26, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Decatur Center for Nursing and Healing LLC, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 121
Deficiencies: 0
Jun 26, 2025
Visit Reason
A Health revisit survey was conducted June 25, 2025, through June 26, 2025, at Decatur Center for Nursing and Healing to verify correction of deficiencies cited during the Recertification in conjunction with a Complaint Investigation survey that concluded on April 24, 2025.
Findings
All deficiencies cited as a result of the prior Recertification and Complaint Investigation survey were found to be corrected.
Inspection Report
Routine
Census: 123
Deficiencies: 11
Apr 24, 2025
Visit Reason
A standard survey was conducted from April 22, 2025 through April 24, 2025, including investigation of four complaint intake numbers, three of which were unsubstantiated and one substantiated without deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inconsistent documentation and implementation of advance directives, failure to maintain clean HVAC PTAC unit grills, medication administration errors, inadequate nail care, improper oxygen administration and storage, failure to complete gradual dose reduction for psychotropic medication, unlocked medication carts, unlabeled and expired medication supplies, improper puree food preparation, unclean ice machines, improperly stored food items, missing baseline care plan summary for one resident, and failure to disinfect glucometer after use.
Complaint Details
Complaint Intake Numbers GA00253619, GA00253719, and GA00253920 were unsubstantiated. Complaint Intake Number GA00253434 was substantiated without deficiency.
Severity Breakdown
SS= D: 9
SS= E: 1
SS= F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to assure consistent documentation and implementation of advance directives for residents R167 and R69. | SS= D |
| Failed to maintain clean PTAC unit grills in two rooms, increasing infection risk. | SS= D |
| Medication administration error: incorrect dosage withdrawn and nearly administered to resident R10. | SS= D |
| Failed to provide nail care for resident R45, risking comfort and infection. | SS= D |
| Failed to follow physician orders for oxygen administration for resident R45 and improper storage of oxygen nasal cannula for resident R96. | SS= D |
| Failed to complete gradual dose reduction for psychotropic medication for resident R36. | SS= D |
| Medication carts left unlocked on 100 and 200 halls; glucometer strips without open date; expired nutritional supplements not removed. | SS= D |
| Failed to follow recipe, use measuring devices, and utensils when preparing puree foods for seven residents. | SS= E |
| Failed to maintain cleanliness of two ice machines and properly store food items in refrigerators and freezers on First and Second Floors. | SS= D |
| Failed to have evidence of a readily accessible baseline care plan summary for resident R96. | SS= D |
| Failed to disinfect glucometer after use for resident R50, risking infection transmission. | SS= D |
Report Facts
Residents present: 123
Sample size: 43
Rooms with unclean PTAC grills: 2
Residents reviewed for medication administration: 8
Residents reviewed for nail care: 3
Residents on oxygen: 15
Residents reviewed for unnecessary medications: 5
Medication carts observed unlocked: 2
Expired nutritional supplement bottles: 6
Residents on puree diet: 7
Ice machines observed unclean: 2
Residents sampled: 43
Residents reviewed for glucometer disinfection: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Withdrew incorrect medication dose for R10 |
| RN BB | Registered Nurse | Left medication cart unlocked and failed to disinfect glucometer |
| Cook GG | Prepared puree food without recipe, measuring devices, or utensils | |
| Maintenance Director | Confirmed responsibility for cleaning ice machines | |
| Director of Nursing | DON | Provided multiple confirmations on expectations and deficiencies |
| Social Services Director | SSD | Confirmed backlog in uploading baseline care plans |
| Assistant Director of Nursing | ADON | Confirmed advance directive documentation inconsistencies and medication dosage error |
| Unit Manager | UM | Confirmed medication cart locking expectations and glucometer disinfection procedures |
| Consultant Pharmacist | Discussed gradual dose reduction process and lack of dose reduction for R36 |
Inspection Report
Life Safety
Census: 123
Capacity: 140
Deficiencies: 0
Apr 24, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Annual Inspection
Census: 123
Deficiencies: 8
Apr 24, 2025
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to follow dietary service procedures for puree food preparation, medication management issues such as unlocked medication carts and expired supplements, failure to disinfect glucometer machines, inadequate nail care for a resident, missing baseline care plan summary for a resident, unclean PTAC unit grills, unclean ice machines and improperly stored food items in unit refrigerators and freezers, and failure to conduct a fingerprint criminal background check for the Administrator.
Deficiencies (8)
| Description |
|---|
| Facility failed to follow recipe, use measuring devices, and utensils when preparing puree food for seven residents. |
| Facility failed to lock two of six medication carts and had expired nutritional supplements and unlabeled glucometer strips. |
| Failed to disinfect glucometer machine after use for one resident, increasing infection risk. |
| Failed to provide nail care for one resident, risking comfort and infection. |
| Failed to have evidence of a readily accessible baseline care plan summary for one resident. |
| Failed to maintain clean PTAC unit grills in two resident rooms, risking infection and allergies. |
| Failed to maintain cleanliness of two ice machines and properly store food items in two unit refrigerators and freezers. |
| Failed to ensure fingerprint criminal background check was conducted for the Administrator. |
Report Facts
Residents on puree diet: 7
Medication carts unlocked: 2
Expired nutritional supplement bottles: 6
Residents reviewed for nail care: 3
Residents sampled for baseline care plan: 43
Rooms with unclean PTAC grills: 2
Ice machines unclean: 2
Employees reviewed for background check: 10
Facility census: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook GG | Cook | Observed preparing puree food without following recipe or using measuring devices and utensils. |
| LPN AA | Licensed Practical Nurse | Observed leaving medication cart unlocked on 100 hall. |
| RN BB | Registered Nurse | Observed leaving medication cart unlocked on 200 hall and failing to disinfect glucometer machine. |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding expectations for medication cart security, glucometer disinfection, nail care, and baseline care plan documentation. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding expectations for recipe use, measuring devices, utensil use, and food storage. |
| Administrator | Administrator | Interviewed regarding expectations for food policies, medication cart security, ice machine cleanliness, and background check compliance. |
| Human Resources Director | HR Director | Interviewed regarding fingerprint criminal background check process and lack of awareness of Administrator's requirement. |
| Certified Nursing Assistant HH | Certified Nursing Assistant | Reported resident R45 required total care assistance and confirmed nail care needs. |
| Unit Manager CC | Unit Manager | Interviewed regarding medication cart locking and expired nutritional supplements. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed expired nutritional supplements in medication room. |
Inspection Report
Deficiencies: 0
Jan 30, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Decatur Center for Nursing and Healing LLC, indicating a regulatory inspection was completed.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Follow-Up
Census: 122
Deficiencies: 0
Jan 30, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in a prior Complaint Investigation survey concluded on December 11, 2024.
Findings
All deficiencies cited in the previous Complaint Investigation survey were found to be corrected during this revisit survey.
Complaint Details
This visit was a follow-up to a Complaint Investigation survey concluded on December 11, 2024, verifying correction of cited deficiencies.
Report Facts
Facility census: 122
Inspection Report
Annual Inspection
Census: 123
Deficiencies: 3
Dec 11, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Decatur Center for Nursing and Healing, LLC.
Findings
The facility was found deficient in providing scheduled showers/baths for one resident, improper food storage practices in the kitchen, and failure to maintain garbage dumpsters with tightly fitting lids and closed doors. These deficiencies had potential impacts on resident care and facility sanitation.
Deficiencies (3)
| Description |
|---|
| Failure to provide showers/baths for one of six sampled residents (R12) as scheduled. |
| Opened food stored in one walk-in cooler was not covered, labeled, or dated. |
| One garbage dumpster was missing a tightly fitted lid and the sliding door was not kept closed. |
Report Facts
Facility census: 123
Residents affected by food storage deficiency: 121
Sampled residents for bathing review: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook EE | Confirmed the bag of cabbage was opened without a label or open date. | |
| Director of Nursing | Director of Nursing | Confirmed shower schedule and that resident R12 should have received a shower on 7/24/2024. |
| Dietary Manager | Dietary Manager | Observed open food in walk-in cooler and garbage dumpster issues. |
| Maintenance Director | Confirmed awareness of missing garbage dumpster lid and contact with county. | |
| Administrator | Administrator | Interviewed regarding missing garbage dumpster lid and was not aware of the issue. |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 5
Dec 11, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint intake numbers initiated on December 2, 2024, and concluded on December 11, 2024.
Findings
The facility was found deficient in several areas including inaccurate Minimum Data Set (MDS) assessments related to falls, failure to administer scheduled medications within the required time frame, failure to provide showers/baths as scheduled for residents, improper food storage practices, and inadequate garbage dumpster maintenance.
Complaint Details
The survey was initiated based on multiple complaint intake numbers. The complaints included issues with inaccurate MDS assessments, medication administration delays, inadequate bathing assistance, food storage violations, and improper garbage disposal practices. Substantiation status is not explicitly stated.
Severity Breakdown
SS= D: 3
SS= F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) assessments were accurate for one resident (R12) reviewed for falls. | SS= D |
| Failed to administer scheduled medication within 60 minutes before or after the scheduled time for one resident (R13) reviewed for medication administration. | SS= D |
| Failed to provide showers/baths as scheduled for one resident (R12) reviewed for Activities of Daily Living (ADLs). | SS= D |
| Failed to ensure opened food stored in one walk-in cooler was covered, labeled, and dated, potentially affecting 121 residents. | SS= F |
| Failed to ensure one garbage dumpster had a tightly fitted lid and that the sliding door was kept closed when not in use. | SS= F |
Report Facts
Facility census: 123
Residents reviewed for falls: 4
Residents reviewed for medication administration: 3
Residents reviewed for ADLs: 6
Residents potentially affected by food storage issue: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KK | MDS Assessment Nurse | Interviewed regarding the inaccurate MDS assessment for resident R12. |
| JJ | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration timing. |
| DON | Director of Nursing | Interviewed regarding medication administration policy and shower schedule. |
| EE | Cook | Interviewed regarding uncovered and unlabeled bag of cabbage in walk-in cooler. |
| DM | Dietary Manager | Interviewed during kitchen tour about food storage and garbage dumpster issues. |
| Administrator | Interviewed regarding awareness of missing garbage dumpster lid. | |
| Maintenance Director | Interviewed regarding missing garbage dumpster lid and notification to county. |
Inspection Report
Routine
Census: 113
Deficiencies: 0
May 20, 2024
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, having implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 113
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Jul 14, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaints GA00233842, GA00234788, GA00235044, and GA00236885.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
Complaints GA00233842, GA00234788, GA00235044, and GA00236885 were investigated and found to be unsubstantiated.
Report Facts
Resident census: 109
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 12, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN between 06/05/2023 and 06/11/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's NHSN during a required seven-day period. | F |
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
May 18, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Decatur Center for Nursing and Healing LLC following a survey completed on May 18, 2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 115
Deficiencies: 0
May 18, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 24, 2023 Recertification and Complaint Survey.
Findings
All deficiencies cited in the prior March 24, 2023 survey were found to be corrected during the May 18, 2023 revisit survey.
Report Facts
Census: 115
Inspection Report
Annual Inspection
Deficiencies: 4
Mar 24, 2023
Visit Reason
A State Licensure survey was conducted at Decatur Center for Nursing and Healing from March 21, 2023 through March 23, 2023 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to hold regular care conferences for residents, inadequate dialysis care and monitoring, improper catheter care leading to risk of urinary tract infections, and environmental sanitation issues such as trash debris, pest presence, and disrepair of furniture and fixtures.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a care conference was held on a regular basis with the resident or resident representative for one of three sampled residents. | D |
| Failure to provide dialysis care and services to meet the needs of two sampled residents, including lack of ongoing assessment and monitoring of dialysis access fistula/catheters. | D |
| Failure to provide appropriate catheter care and hand hygiene by staff, placing a resident at risk for urinary tract infections. | D |
| Failure to maintain a safe and homelike environment, with trash debris, pest presence, peeling wallpaper, damaged furniture, and unsafe electrical outlets observed in multiple resident rooms. | E |
Report Facts
Residents sampled for care conferences: 3
Residents sampled for dialysis care: 2
Residents sampled for catheter care: 35
Dates of survey: March 21, 2023 through March 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nursing Assistant | Named in catheter care deficiency for improper hand hygiene and catheter cleaning. |
| Director of Nursing | Director of Nursing | Confirmed dialysis care plan deficiencies and lack of documentation. |
| Social Services Director | Social Services Director | Interviewed regarding care conference documentation and process. |
| Unit Manager 2 | Unit Manager | Discussed catheter care incident with CNA2. |
| Administrator | Administrator | Provided information about maintenance staffing and facility environment. |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 9
Mar 24, 2023
Visit Reason
A standard survey was conducted from March 21 through March 24, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations and investigate complaints.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to hold regular care conferences, unsafe and unsanitary environment, failure to transmit MDS data, failure to develop baseline care plans, failure to revise care plans to reflect current code status, improper catheter care, failure to assess nebulizer treatment effectiveness, inadequate dialysis care and monitoring, and failure to identify COVID-19 vaccination status upon admission.
Complaint Details
Complaint Intake Numbers GA00233137, GA00233132, GA00226731, GA00226733, GA00226001, GA00224179, GA00223811, GA00222422, GA00220897 were investigated and found to be unsubstantiated.
Severity Breakdown
D: 7
E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a care conference was held regularly with resident or representative for one sampled resident. | D |
| Failed to provide a safe homelike environment; trash debris and furniture disrepair observed. | E |
| Failed to electronically transmit MDS data for one resident. | D |
| Failed to develop baseline care plans for six residents. | E |
| Failed to revise care plan to reflect resident's current full-code status. | D |
| Failed to provide appropriate catheter care and hand hygiene for one resident. | D |
| Failed to assess lung sounds pre- and post-nebulizer treatment for one resident. | D |
| Failed to provide ongoing assessment and monitoring of dialysis access for two residents. | D |
| Failed to identify COVID-19 vaccination status upon admission for one resident. | D |
Report Facts
Complaint Intake Numbers Investigated: 9
Resident Census: 121
Residents Sampled for Care Plans: 35
Residents with Baseline Care Plan Deficiency: 6
Residents with Dialysis Care Deficiency: 2
Residents with Nebulizer Therapy Deficiency: 1
Residents with Catheter Care Deficiency: 1
Residents with COVID-19 Vaccination Deficiency: 1
Inspection Report
Life Safety
Census: 124
Capacity: 140
Deficiencies: 0
Mar 22, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Stories: 2
Construction Type: 2111
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