Inspection Reports for North Decatur Health and Rehabilitation Center
2787 NORTH DECATUR ROAD, DECATUR, GA, 30033
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 4, 2022, found no deficiencies and the complaint investigated at that time was unsubstantiated. Earlier inspections showed a mix of results, with the facility correcting prior deficiencies related to diet orders and other issues. The main themes of past deficiencies included failure to provide physician-ordered diets, medication administration errors, infection control lapses, and maintenance of a safe environment. Complaint investigations throughout the period were mostly unsubstantiated, with no enforcement actions or fines listed in the available reports. The facility appears to have improved over time, resolving earlier deficiencies and maintaining compliance in recent surveys.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
65 residents
Based on a January 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate pressure ulcer care and failure to provide medically-related social services to residents, including issues with discharge planning and wound care management.
Complaint Details
The complaint investigation revealed failures in pressure ulcer care for residents R214, R24, and R215, including lack of skin assessment prior to discharge and failure to provide ordered low air loss mattresses. It also found failures in providing medically-related social services for residents R116 and R54, including delayed home health referrals, lack of communication about discharge letters and Medicaid applications, and absence of a social services policy.
Findings
The facility failed to provide appropriate pressure ulcer care for three residents by not performing required skin assessments prior to discharge and not providing ordered low air loss mattresses. Additionally, the facility failed to ensure medically-related social services were provided to meet the needs of two residents, including failure to timely refer for home health services and lack of communication regarding discharge notices and Medicaid applications.
Deficiencies (2)
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents.
Failed to provide medically-related social services to help residents achieve the highest possible quality of life for two residents.
Report Facts
Residents reviewed for pressure ulcers: 10
Residents sampled for social services: 35
BIMS score: 1
BIMS score: 9
BIMS score: 14
BIMS score: 15
Admission date: Feb 25, 2025
Discharge date: Apr 11, 2025
Discharge date: Mar 22, 2025
Discharge date: May 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding lack of skin assessment prior to discharge of R214 | |
| Director of Nursing | Interviewed regarding expectations for skin assessments prior to discharge and confirmed failure to provide low air loss mattresses | |
| Social Services Director | Interviewed regarding delays and failures in home health referrals and Medicaid application communication | |
| Business Office Manager | Interviewed regarding Medicaid application submission and communication failures | |
| Administrator | Interviewed regarding lack of communication and absence of social services policy | |
| Home Health Supervisor 1 | Interviewed regarding referral issues for R116 | |
| Home Health Supervisor 2 | Interviewed regarding referral receipt for R116 |
Inspection Report
Routine
Deficiencies: 10
Date: May 7, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including medication education, care planning, transfer and discharge procedures, assessment accuracy, pressure ulcer care, social services, medical record maintenance, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to inform residents about medication risks, lack of resident participation in care planning, inadequate transfer and discharge notices, inaccurate Minimum Data Set (MDS) assessments, incomplete and untimely care plan revisions, failure to provide appropriate pressure ulcer care and equipment, insufficient medically related social services, incomplete medical records, and improper use of personal protective equipment (PPE) during care.
Deficiencies (10)
Failed to provide information on the risks and benefits of prescribed psychotropic medications for one resident.
Failed to ensure one resident participated in the development and implementation of their person-centered care plan.
Failed to provide written transfer and bed hold notices with all required information to residents and/or their representatives for three residents.
Failed to ensure accurate Minimum Data Set (MDS) assessments regarding PASARR screenings for two residents.
Failed to develop a comprehensive care plan with person-centered focus and measurable goals for one resident with PTSD.
Failed to revise care plans timely for two residents when pressure ulcers developed.
Failed to provide appropriate pressure ulcer care including skin assessments prior to discharge and placement of low air loss mattresses as ordered for three residents.
Failed to provide medically related social services to meet the needs of two residents, including timely home health referrals and communication regarding Medicaid applications and discharge notices.
Failed to maintain complete medical records including daily skilled documentation for three residents.
Failed to ensure staff used proper personal protective equipment (PPE) during medication administration for one resident on enhanced barrier precautions.
Report Facts
Residents reviewed for care planning: 35
Residents reviewed for pressure ulcers: 10
Residents affected by transfer/discharge notice deficiencies: 3
Residents affected by inaccurate MDS assessments: 2
Residents affected by incomplete medical records: 3
Residents affected by PPE noncompliance: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided expectations on medication education, transfer/discharge notices, care plan accuracy, skin assessments, and PPE use |
| Social Services Director | Social Services Director (SSD) | Discussed care conference, home health referrals, Medicaid application, and discharge notices |
| MDS Coordinator | MDS Coordinator (MDSC) | Confirmed PASARR screening errors and care plan deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Explained interpretation of transfer/discharge form regarding skin assessment |
| Certified Medication Aide | Certified Medication Aide (CMA) 2 | Observed not wearing gown during medication administration for resident on enhanced barrier precautions |
| Family Member | Family Member (FM) 2 | Reported discovering pressure ulcer after resident discharge |
| Family Member | Family Member (FM) 6 | Reported lack of assistance with Medicaid application and discharge communication |
| Home Health Supervisor | Home Health Supervisor (HH) 1 | Reported referral issues for home health services |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to respiratory care, medication storage, and facility maintenance at Harborview Decatur nursing home.
Findings
The facility failed to provide physician orders for oxygen therapy, failed to properly label and maintain oxygen and CPAP equipment, left medication carts unlocked and unattended, and had multiple maintenance issues including disrepair in resident rooms and restrooms. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to provide Medical Doctor's orders for oxygen therapy, failed to provide humidification to the oxygen concentrator, and failed to label/date oxygen tubing for one resident; failed to provide protective plastic bag for CPAP mask and tubing for another resident.
Failed to ensure one of three medication carts was locked and secured when unattended and not within eyesight of a nurse.
Failed to ensure the environment was safe, clean, and comfortable due to disrepair of residents' rooms and restrooms including missing window blind slats, chipped paint, broken bathroom fixtures, holes in walls and doors, and non-functioning hot water.
Report Facts
Oxygen flow rate: 2
Oxygen flow rate: 3
Medication carts: 3
Residents affected: 5
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Assisted resident #59 to reconnect oxygen and provided information about oxygen tubing changes |
| BB | Registered Nurse (RN) | Verified responsibility for unlocked medication cart and admitted forgetting to lock it |
| Director of Nursing | Director of Nursing (DON) | Provided interview regarding expectations for physician orders for oxygen and CPAP, medication cart security, and equipment maintenance |
| Maintenance Director | Maintenance Director | Interviewed regarding repair of facility maintenance issues |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, medication storage, and facility maintenance at Harborview Decatur nursing home.
Findings
The facility failed to provide physician orders for oxygen therapy, proper labeling and humidification of oxygen equipment, and protective storage for CPAP equipment for certain residents. Additionally, medication carts were found unlocked and unattended, and multiple maintenance issues were observed in resident rooms affecting safety and comfort.
Deficiencies (3)
Failed to provide Medical Doctor's orders for oxygen therapy, humidification to the oxygen concentrator, and label/date oxygen tubing for one resident; failed to provide protective plastic bag for CPAP mask and tubing for another resident.
Failed to ensure one of three medication carts was locked and secured when unattended and not within eyesight of a nurse.
Failed to ensure the nursing home environment was safe, clean, and comfortable due to disrepair of residents' rooms and restrooms.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 34
Oxygen flow rate: 2
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Assisted resident R#59 with oxygen and CPAP equipment and provided information about oxygen tubing changes |
| BB | Registered Nurse (RN) | Responsible for medication cart found unlocked and unattended |
| Director of Nursing | Director of Nursing (DON) | Provided interview regarding expectations for physician orders, equipment handling, and medication cart security |
| Maintenance Director | Maintenance Director | Interviewed regarding repair of environmental deficiencies |
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 0
Date: Jan 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00219535.
Complaint Details
Complaint #GA00219535 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Dec 29, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for North Decatur Health and Rehabilitation Center following a survey completed on December 29, 2021.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Dec 29, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the November 10, 2021 survey.
Findings
All deficiencies cited in the prior November 10, 2021 survey were found to be corrected during the December 29, 2021 revisit survey.
Inspection Report
Renewal
Deficiencies: 1
Date: Nov 10, 2021
Visit Reason
The inspection was a Licensure survey conducted from 11/8/2021 to 11/10/2021 to assess compliance with regulatory requirements for the facility license renewal.
Findings
The facility failed to ensure that one of four sampled residents (R#41) was served a vegetarian diet as ordered by the physician. The Dietary Manager confirmed that non-vegetarian items were served to the resident despite the vegetarian diet order, which was an oversight by staff.
Deficiencies (1)
Failure to provide a vegetarian diet as ordered by the physician for resident #41.
Report Facts
Number of sampled residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed the vegetarian diet order was not followed and acknowledged oversight by staff. |
| Corporate Dietary Manager | Corporate Dietary Manager | Provided information on facility policy regarding food preferences and assessments. |
Inspection Report
Routine
Census: 81
Deficiencies: 1
Date: Nov 10, 2021
Visit Reason
A standard survey was conducted from 11/8/2021 through 11/10/2021, including investigation of multiple complaint intake numbers (GA00218823, GA00212930, GA00218096, GA00217921). The survey aimed to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
The survey included investigation of complaint intake numbers GA00218823, GA00212930, GA00218096, and GA00217921 in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, specifically failing to provide a resident (R#41) with a physician-ordered vegetarian diet. Observations and interviews confirmed the resident was served non-vegetarian items despite documented orders and preferences.
Deficiencies (1)
Failure to ensure one resident was served a vegetarian diet as ordered by the physician, including serving non-vegetarian items such as hamburger steak, fish fillet, and boiled eggs.
Report Facts
Resident census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed resident received non-vegetarian food despite vegetarian diet order |
| Corporate Dietary Manager | Corporate Dietary Manager | Confirmed facility policy requires assessment of resident food preferences within 48 hours of admission |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 10, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, including ensuring residents receive diets as ordered by physicians.
Findings
The facility failed to ensure that one sampled resident (R#41) was served a vegetarian diet as ordered by the physician. Despite documented orders and resident preferences, non-vegetarian items were served, causing inconvenience to the resident.
Deficiencies (1)
Failure to provide a resident with a nourishing, palatable, well-balanced vegetarian diet as ordered by the physician.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding failure to follow vegetarian diet order for resident R#41. |
| Corporate Dietary Manager | Corporate Dietary Manager | Interviewed regarding facility policy on resident food preferences and assessments. |
Inspection Report
Life Safety
Census: 63
Capacity: 72
Deficiencies: 0
Date: Nov 9, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.
Findings
The facility was found to be in compliance with the Life Safety Code requirements, including the Emergency Preparedness Program and NFPA 101 Life Safety Code 2012 edition standards.
Inspection Report
Routine
Census: 38
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
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, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00206393, #GA00207071, #GA00209862, and #GA00201904.
Complaint Details
Complaints #GA00206393, #GA00207071, #GA00209862, and #GA00201904 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: Nov 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Date: Jul 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195881.
Complaint Details
Complaint GA00195881 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 19, 2019
Visit Reason
A complaint survey was conducted on 2/18/19 - 2/19/19 to investigate complaint GA00194841 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00194841 was investigated and no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 7, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Jan 31, 2019
Visit Reason
A Revisit Survey to the Standard Survey of December 6, 2018 was conducted to verify correction of previously cited deficiencies.
Findings
All deficiencies cited during the Standard Survey had been corrected.
Inspection Report
Routine
Census: 61
Deficiencies: 11
Date: Dec 6, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including safe environment maintenance, comprehensive assessments, baseline and comprehensive care plans, medication management, infection control, and immunization documentation.
Deficiencies (11)
Facility failed to maintain a safe, clean, comfortable, and homelike environment in nine resident rooms with issues such as dust, peeling paint, stained curtains, and cobwebs.
Failed to conduct comprehensive assessments including depression assessment for resident #24.
Failed to develop baseline care plan within 48 hours of admission for resident 'A' related to constipation care.
Failed to develop and implement comprehensive care plans for residents #55, #38, #214, and #29 including restorative care, ADL care, and oxygen therapy.
Failed to provide restorative nursing care for resident #55 related to range of motion and splint use.
Failed to maintain respiratory and tracheostomy care equipment in a sanitary manner for residents #29, #38, and #3; improper tracheostomy care technique observed.
Resident #17 had duplicated medication orders leading to unnecessary drug therapy; resident #54 received incorrect vitamin D dosage.
Medication error rate exceeded 5% with 4 errors in 29 medication opportunities for residents #17 and #54.
Facility failed to discard expired medications found in supply room including mineral oil and cough syrup.
Facility failed to maintain infection control standards including unlabeled personal care items and improper hand hygiene during tracheostomy care.
Facility failed to document influenza vaccine refusal rationale and provide vaccine information statement (VIS) and pneumococcal vaccine offering and VIS to resident #24 and resident 'B'.
Report Facts
Resident census: 61
Medication error rate: 13.79
Medication opportunities observed: 29
Medication errors: 4
Resident sample size: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse | Administered medications with errors and performed tracheostomy care without proper hand hygiene |
| BB | Registered Nurse | Verified medication errors and infection control concerns during survey |
| GG | Certified Nursing Assistant | Reported on restorative nursing care for resident #55 |
| AA | Certified Nursing Assistant | Reported on nail care duties and resident assignments |
| DON | Director of Nursing | Interviewed regarding care plan and immunization documentation issues |
Inspection Report
Life Safety
Census: 65
Capacity: 73
Deficiencies: 1
Date: Dec 6, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to address corrosion on 3 to 4 sprinkler heads as noted on a yellow tag dated 05/08/2018, which could place 10 residents and 5 staff at risk if the sprinkler heads do not activate properly.
Deficiencies (1)
Failure to comply with sprinkler system maintenance and testing requirements; 3 to 4 sprinkler heads needed cleaning or replacement due to corrosion.
Report Facts
Residents at risk: 10
Staff at risk: 5
Census: 65
Total licensed beds: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system yellow tag during facility tour |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 6, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at North Decatur Health and Rehabilitation Center.
Findings
The inspection identified multiple deficiencies including infection control lapses such as unlabeled and unbagged personal care items, improper hand hygiene during tracheostomy care, medication administration errors including incorrect dosages and duplicated orders, inadequate nursing care related to personal hygiene and care plan implementation, failure to ensure use of splinting devices as ordered, and incomplete documentation and education regarding influenza and pneumococcal vaccinations.
Deficiencies (5)
Infection control procedures not followed: unlabeled and unbagged personal care items observed in resident bathrooms and improper hand hygiene during tracheostomy care.
Medication administration errors including failure to administer correct dosage of vitamin D3 and duplicated medication orders.
Nursing care deficiencies including failure to provide assistance with activities of daily living such as nail care and personal hygiene as per care plan.
Failure to ensure resident wore prescribed splinting devices as ordered and lack of documentation of restorative services.
Failure to document influenza vaccine refusal properly and to provide required vaccine information sheet (VIS) education to resident or responsible party; lack of documentation regarding pneumococcal vaccine education and administration.
Report Facts
Medication dosage: 2000
Medication dosage: 25
Medication dosage: 150
Medication dosage: 10
Medication dosage: 5
Medication dosage: 600
Medication dosage: 400
Medication dosage: 1000
Medication dosage: 60
Medication dosage: 300
Medication dosage: 20
Medication dosage: 81
Medication dosage: 8.6
Medication dosage: 30
Medication dosage: 17
Splinting duration: 8
Splinting schedule: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse | Named in infection control and medication administration findings |
| BB | Registered Nurse | Verified infection control concerns and medication order discrepancies |
| AA | Certified Nursing Assistant | Interviewed regarding daily care and nail care practices |
| GG | Certified Nursing Assistant | Interviewed regarding splinting device application and resident care |
| Director of Clinical Services | Interviewed regarding infection control and vaccine documentation | |
| Director of Nursing | Interviewed regarding vaccine education and resident care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 30, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00192378 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaint #GA00192378; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 13, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00190487 and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaint #GA00190487; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey conducted on 9/13/2018 to 9/14/2018.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 0
Date: Apr 13, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey on 2018-02-23.
Findings
All deficiencies cited as a result of the 2/23/18 standard survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 26, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted by the surveyor.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 16, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186425 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186425 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Routine
Census: 66
Deficiencies: 5
Date: Feb 23, 2018
Visit Reason
A Federal Monitoring Survey was conducted to assess compliance with Medicare and Medicaid regulations for long term care facilities.
Findings
The facility was found non-compliant with multiple regulatory requirements including medication administration without physician orders, improper catheter care, expired and incorrectly administered medications, food safety violations, and inadequate infection control practices related to glucometer disinfection.
Deficiencies (5)
Failure to ensure residents had a physician's order for intramuscular medication before administration and medications were given as prescribed.
Failure to provide catheter care to prevent urinary tract infections.
Failure to ensure residents received medications as prescribed and did not receive expired medications.
Failure to ensure food items were properly labeled, stored at correct temperatures, and kitchen equipment was clean and sanitary to prevent cross-contamination.
Failure to maintain an effective infection prevention and control program, specifically failure to follow policy for glucometer disinfection and placement after cleaning.
Report Facts
Residents sampled: 26
Residents affected: 1
Residents affected: 1
Residents affected: 60
LPNs observed: 3
Residents observed: 3
Inspection Report
Life Safety
Census: 65
Capacity: 73
Deficiencies: 4
Date: Feb 22, 2018
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted by CMS following a state survey to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and related NFPA codes.
Findings
The facility was found not in substantial compliance with life safety code requirements, including issues with egress door hardware height, cooking equipment installation, corridor door latching and smoke resistance, and smoke barrier fire resistance due to penetrations.
Deficiencies (4)
Egress doors had latching hardware installed above the maximum allowed height of 48 inches AFF, affecting four doors.
Cooking equipment in the kitchen failed to meet NFPA 96 requirements; specifically, a deep fat fryer was installed too close to a surface flame cooktop without the required baffle plate.
Corridor doors failed to maintain required latching and smoke resistance; one door had a kick down stop preventing self-closing and did not latch, another door had a hole compromising integrity.
Smoke barrier at resident room 15 was penetrated by conduit, wires, and pipes with failed firestopping resulting in gaps compromising the ½-hour fire resistance rating.
Report Facts
Number of affected doors: 4
Gap size: 0.5
Distance fryer installed from cooktop: 4
Required minimum distance fryer from cooktop: 16
Door gap: 1.5
Hole size: 0.375
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present and identified smoke barriers and deficiencies | |
| Maintenance Director | Present when deficiencies were identified |
Inspection Report
Routine
Census: 65
Deficiencies: 0
Date: Jan 25, 2018
Visit Reason
A standard survey was conducted at North Decatur Health and Rehabilitation Center from January 23, 2018 through January 25, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 65
Capacity: 73
Deficiencies: 0
Date: Jan 23, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements, including the emergency preparedness plan and fire safety standards.
Report Facts
Certified Beds: 73
Census: 65
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 25, 2017
Visit Reason
Complaint investigation was conducted on 8/24/17 and 8/25/17 involving staff and resident interviews and facility observations.
Complaint Details
Complaint investigation was conducted and found to be unsubstantiated.
Findings
Based on the information obtained during the investigation, the complaint was unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 28, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the recertification survey on 2017-02-09.
Findings
All deficiencies cited as a result of the recertification survey on 2017-02-09 were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 66
Capacity: 73
Deficiencies: 0
Date: Feb 7, 2017
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 life safety code requirements related to fire safety and the National Fire Protection Association standards.
Viewing
Loading inspection reports...
