Harborview Decatur

Based on interview and record review, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to provide information on the risks and benefits of prescribed psychotropic medications for one of five Residents (R) (R165) reviewed for unnecessary medications. This failure placed residents at risk of not knowing what their medications were and potential adverse side effects. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 1/1/2023, revealed, . The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options . and document such attempts in the clinical record, including discussions with the resident and/or resident representative . Review of R165's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R165 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs). Review of R165's Order Summary,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to ensure one of 35 sampled Residents (R) (R165) reviewed for care planning was afforded the right to participate in their care planning process. This failure placed residents at risk of not being aware of the goals and outcomes of their care. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 1/1/2023, revealed, . The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options . and document such attempts in the clinical record, including discussions with the resident and/or resident representative . Review of R165's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R165 admitted was to the facility on 4/29/2025 with diagnoses that included quadriplegia (paralysis of all four limbs). During an initial interview on 5/4/2025 at 1:36 pm, R165 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advise]), the facility failed to ensure three of nine Residents (R) (R22, R25, and R40) and/or their Resident Representative (RR or Family Member (FM) received a written notice of transfer and/or a written bed hold notice that included all required information who were reviewed for hospitalization. This failure had the potential to affect the resident and their Resident Representative (RR or FM) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advise]), reviewed/revised 7/1/2024, revealed, . The facility's transfer/discharge notice will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the RAI (Resident Assessment Instrument) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two of three sampled Residents (R) (R1 and R43) reviewed for Preadmission admission Screening and Resident Review (PASARR). This failure had the potential to affect the care planning and provision of needed services. Finding include: Review of the October 2024 RAI Manual, page A-30 regarding Section A1500 of the MDS revealed, . All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions (please contact your local State Medicaid Agency for details regarding PASRR requirements and exemptions) . Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, review of the facility's policy titled, Comprehensive Care Plans, and the Resident Assessment Instrument (RAI) manual, the facility failed to develop a comprehensive care plan with a person-centered focus, measurable goal, and resident-specific interventions for one of 35 sampled Resident (R) (R 34). Specifically, the facility failed to develop a comprehensive care plan related to post-traumatic stress disorder (PTSD) for R34. This failure placed residents at risk of increased psychosocial distress and a diminished quality of life. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 1/1/2023, revealed, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to ensure the comprehensive care plan was revised/updated for two of 10 Residents (R) (R24 and R34) reviewed for pressure ulcers. The facility failed to revise the Skin Integrity Care Plan when R24 and R34 developed pressure ulcers. This failure placed residents at risk of unmet care needs. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 1/1/2023, revealed, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment . 1. Review of R24's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R24 was admitted to the facility on [DATE] with diagnoses that included a stroke with left-side paralysis. Review of the admission MDS, located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility's policies titled, Wound Treatment Management, and Skin Assessments, the facility failed to provide care and services related to pressure ulcers for three of 10 Residents (R) (R214, R24, and R215) reviewed for pressure ulcers. Specifically, the facility failed to ensure a skin assessment was completed prior to R214's discharge to home where it was discovered he had a buttock pressure ulcer. In addition, the facility failed to ensure a low loss air mattress (a specialized medical mattress designed to prevent and treat pressure ulcers by providing constant airflow and alternating pressure) was placed on R24 and R215's bed per the wound care physician's order. These failures placed the residents at risk of unidentified and worsening wound care needs. Findings include: Review of the facility's policy titled, Wound Treatment Management, dated 3/1/2024, revealed, . To promote wound healing of various types of wounds, it is the policy of this facility to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medically related social services were provided to meet the needs of two of 35 sampled Residents (R) (R116 and R54). This failure had the potential to affect the safety and well-being of the residents and their caregivers and help prevent re-admission. Findings include: Review of the facility provided Director of Social Services Job Functions: Duties and Responsibilities revealed, Develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident . Participate in discharge planning, development and implementation of social care plans and resident assessments . Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. 1. Review of R116's admission Record, from the Profile tab of the electronic medical record (EMR), showed an admission date of 2/25/2025 with medical diagnoses that included type II…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain a complete medical record for three of 35 sampled Residents (R) (R164, R165, and R215). The failure placed the residents at risk of unmet care needs. Findings include: 1. Review of R164's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R164 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure. Review of R164's daily Skilled Documentation, located in the Assessments tab of the EMR, revealed no Skilled Documentation on 4/29/2025 and 5/4/2025. 2. Review of R165's admission Record, located in the Profile tab of the EMR, revealed R165 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (a paralysis of all four limbs). Review of R165's daily Skilled Documentation, located in the Assessments tab of the EMR, revealed no Skilled Documentation on 5/4/2025. 3. Review of R125's admission Record, located in the Profile tab of the EMR,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and review of the facility's policy titled, Enhanced Barrier Precautions, the facility failed to ensure staff used proper personal protective equipment (PPE) with a resident who required enhanced barrier precautions (EBP) for one of three Residents (R) (R32) observed for medication administration. The deficient practice to not perform adequate infection control practices increases the risk of cross contamination and spread of infection. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, last revised 3/1/2025, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Definitions: 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . PPE for enhanced barrier precautions is only necessary when performing high-contact care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations,staff interviews, and review of the facility's policy titled, 'Maintenance Inspection, the facility failed to ensure that the environment was safe, clean, and comfortable for residents, related to disrepair of residents' rooms and restrooms. Findings include: Review of the facility's policy titled, Maintenance Inspection dated 3/1/2023 revealed It is the policy of this facility to utilize a maintenance inspection checklist in order to assure safe functional, sanitary, and comfortable environment for residents, staff and the public. During a tour of the facility on 6/5/2023 at 10:30 a.m. the following observations were made: In resident rooms 1, 4, 5, 6, 8, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 29, 32, and 34, the window blinds on the full-length sliding glass doors had missing slats, preventing the blinds from completely closing and providing privacy from the outside. In room [ROOM NUMBER] the paint was chipped and peeling under the window and the bathroom pullcord…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident and staff interviews, record review, and the facility's policy titled, Oxygen (O2) Administration, the facility failed to provide Medical Doctor's (MD) orders for O2, to provide humidification to the O2 concentrator, and label/date O2 tubing for one of five Residents (R) (R#59) reviewed for O2 therapy. Also, the facility failed to provide a protective plastic bag to cover the Continuous Positive Airway Pressure (CPAP) mask and tubing for one of five Residents (R) (R#216) reviewed for respiratory treatment. Findings include: Review of the facility's policy titled, Oxygen Administration dated 3/1/2022 revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and references. The Policy Explanation and Compliance Guidelines section revealed: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 5. b. Change oxygen tubing, supplies, and mask/cannula weekly and as needed if it becomes soiled or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled, Storage of Medications, the facility failed to ensure one of three medication carts was locked and secured when the cart was unattended and not within eyesight of a nurse. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications. Findings include: Review of the facility's policy's titled, Storage of Medications, dated November 2020 revealed a policy of: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The Policy Interpretation and Implementation indicated: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and record review, the facility failed to ensure one of four sampled residents, (R)#41, was served a vegetarian diet ordered as ordered by the Physician. Findings include: Review of the policy titled Dining and Food Preferences , revised 9/2017, documented that the Dining Service Director or designee will interview the Resident or Resident's representative to complete the food preference interview within 48 hours of admission. The food preferences interview will be entered into the medical record. Food intolerance and food dislikes will be entered into the resident profile in the menu management software system. Record review revealed that R#41 was admitted to the facility on [DATE] with diagnoses included syncope and collapse, fall, bone density disorder, and unstageable left hip pressure ulcer. Record review for R#41 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE], which documented a Brief Interview for Mental Status (BIMS) summary score of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.