Harborview Decatur

In the surveyor’s words

From the most serious findings on record at Harborview Decatur, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF921Jun 8, 2023

  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. […]

• No harm, potential for more than minimal, isolatedF552May 7, 2025

  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 . […]

• No harm, potential for more than minimal, isolatedF553May 7, 2025

  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 . […]

• No harm, potential for more than minimal, isolatedF628May 7, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF641May 7, 2025

  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, . […]