Neighborhoods Rehabilitation and Skilled Nursing B

Inspectors wroteBased on interview and record review, facility staff failed to provide an appropriate emergency discharge notice to one resident (Resident #1) when staff discharged the resident to the hospital and refused to allow him/her to return to the facility. The facility census was 93.1. Review of the facilities policies did not contain a policy for emergency discharge.2. Review of Resident #1's face sheet, dated 5/29/26, showed the resident admitted to the facility on [DATE] and staff discharged him/her to the local hospital on 5/20/26. Review of the resident's progress notes, dated 5/20/26 at 11:48 A.M., showed staff documented the resident discharged back to the hospital for uncontrolled pain. Review of the resident's medical records did not contain documentation of an emergency discharge issued to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to label eye drops and nasal sprays in accordance with professional standards and failed to destroy expired medications for three medication carts and one medication room. The facility census was 88.1. Review of the facility's Medication Storage policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of eye drops or nasal sprays. Review of the facility's Administration of Eye Drops policy, dated 2001, showed the policy directed staff to label new bottles with date opened and follow facility policy or manufacturer's instructions for when to discard and replace the bottle. Review of the facility's Administration of Nasal Spray Administration policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of nasal sprays.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff to ensure waste containers in food preparation areas remained covered when not in use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed maintain the internal temperature of hot foods held in the steamtable at a minimum of 140 degrees Fahrenheit (dF) to prevent the growth of food-borne pathogen. Facility staff also failed to ensure staff involved in food preparation and service wore effective hair restraints to prevent physical contamination of food and food contact surfaces. These failures had the potential to affect all residents. The facility census was 88. Based on observation, interview and record review, the facility staff to ensure waste containers in food preparation areas remained covered when not in use. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide Enhanced Barrier Precautions (EBP) during wound care for two (Residents #5 and #15) of five residents who had a wound and one (Resident #5) of two residents who had a catheter. The facility staff failed to provide appropriate hand hygiene between glove changes during the provision of care for one (Residents #5) of six residents. The facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for tuberculosis (TB)) was completed in accordance with their policy and on file for eight employees (Housekeeper J, Certified Medication Technician (CMT) K, Certified Nurse Aide (CNA) L, Housekeeper M, Dietary Aide (DA) N, Licensed Practical Nurse (LPN) O, Social Service Designee (SSD), and the Assistant Business Office Manager (ABOM) out of ten sampled employees. [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to obtain written consent from the resident or his/her designee, guardian and conservator, or conservator to manage the personal funds of the resident in the facility resident trust account for four residents (Residents #31, #68, #121 and #122) out of nine sampled residents. Facility staff also failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds to preclude the commingling of resident funds with facility funds for one resident (Resident #124) out of two sampled residents and ensure timely refunds for five residents (Residents #121, #122, #123, #124, #125) out of six sampled discharged residents. The facility census was 88. 1. Review of the facility's policy titled, Resident Personal Fund, revised 01/05/25, showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered care plan to included behavioral interventions and activity preferences for three of three sampled residents (Resident #2, #5 and #9) who resided on a secured memory care unit. The facility census was 88. 1. Review of the facility's Dementia Care policy, dated 2025, showed individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to review and revise the comprehensive care plan for three of three sampled residents (Resident #2, #6, and #9) who had falls and failed to update the care plan for one resident (Resident #5) of two sampled residents with pressure ulcers (wound created from pressure). The facility census was 88. Review of the Comprehensive Care Plan policy, dated 2025, showed the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for catheter use and indication, catheter size and bulb size for catheters on two of two sampled residents (Resident #8 and #111) and failed to document and obtain orders for dialysis to include days of week, location of clinic, and indication for two of two residents (Resident #2 and #5) who received dialysis. The facility census was 88.1. Review of the facility's Catheter Care policy, undated, showed the policy did not contain direction or guidance for contents of a physician order for catheters. 2. Review of Resident #2's Significant Change of Status (SCS) Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/07/25, showed staff assessed the resident as: [...]

Inspectors wroteBased on interview, and record review, facility staff failed to meet professional standards of practice when facility staff failed to transcribe physician's orders for one resident (Resident #3) and failed to complete weekly skin assessments for three residents (Resident #2, #3, and #5) out of five sampled residents. The facility census was 86. 1. Review of the facilities Physician Orders policy, undated, showed staff are directed as follows:-All physicians orders should be carried out as ordered upon the signed order of a person lawfully authorized to prescribe;-Each order should be noted and processed according to the standards of practice;-The order will be input into the electronic medical record system and then will populate into the proper areas for administration. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to monitor one resident (Resident #1) at least every two-hours per facility policy and based on resident needs. Staff did not monitor the resident between the hours of 11:00 P.M. and 3:10 A.M. Resident #1 was found entrapped in the bedrail, face down in the mattress, unresponsive, and he/she passed away. The facility census was 89. The administrator was notified on [DATE] of Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. The Administrator immediately terminated Licensed Practical Nurse (LPN) C, suspended Certified Nursing Assistant (CNA) B pending the results of the investigation, conducted an investigation, and in-serviced all staff on rounding on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to re-assess bedrail use after a significant change in condition per policy for one resident (Resident #1). Resident #1 was found entrapped in the bedrail, found face down in the mattress and unresponsive, resulting in his/her death. The facility census was 89. The administrator was notified on 09/03/2025 of an Immediate Jeopardy which began on 08/26/2025. The IJ was removed on 09/03/2025, as confirmed by surveyor onsite verification. 1. Review of the facility's Proper Use of Bed Rails policy, undated, showed staff are to ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, or depth. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards when staff failed to transcribe wound care orders for two resident's (Resident #3 and #4) who had wounds. Facility staff failed to document they provided wound care as ordered for one resident (Resident #4) of one sampled resident. The Facility's censes was 90. 1. Review of the Facility's Consulting Physician/Practitioner Orders policy, undated, showed: -Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's: wound clinic physician and Nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during wound care, failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for one resident (Resident #4) with wounds out of one sampled residents. The facility's census was 90. 1. Review of the Facility's Hand Hygiene policy, undated, showed staff are directed as follows: -All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves; -Hand Hygiene Table: [...]

Inspectors wroteBased on interview and record review, facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for resident (Resident #1) with a signed full code physician order. The facility census is 86. The administrator was notified on [DATE] of past noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. Administration immediately in-serviced nursing staff on CPR, code status, and two-way radio communication policies. The IJ was corrected on [DATE]. Review of the facility's CPR policy, undated and reviewed/revised on [DATE], directed staff to adhere to residents' rights to formulate advance directives. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. [...]

Inspectors wroteBased on interview and record review, facility staff failed to report to the Department of Health and Senior Services (DHSS) neglect of one resident (Resident #1), when facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for the resident with a signed full code physician order. The facility's census was 86. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, undated, showed staff are directed as follows: -Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; -The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law; [...]

Inspectors wroteBased on observation, interviews, and record review, facility staff failed to store medications in a safe and effective manner in three medication rooms and one medication cart. The facility census was 91. 1. Review of the facility's Medication Storage policy, undated, showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation moisture control, and security. 2. Observation on 11/12/24 at 4:08 P.M., the Booneslick hall medication room contained: -One 10 inch medical tubing with the expiration date of 04/17/23; -One three mililiter (ml) needleless syringe with an expiration date of 07/31/22. 3. [...]

Inspectors wroteBased on interviews, and record review the facility staff failed to ensure the resident's call lights were answered in a timely manner. The facility's census was 91. 1. Review of the facility's Call lights: Accessibility and Timely Response policy, undated, showed all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 2. Review of room [ROOM NUMBER], Bed 2's the electronic call light report showed: -On 11/06/24 at 9:47 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 10:43 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; [...]

Inspectors wroteBased on interview and record review, staff failed to maintain a professional standard of care when staff failed to document follow-up when a medication unavailable, document physician notification when the medication unavailable, and document any adverse effects from lack of medication administration for one (Resident #36) out of five sampled residents. The facility census was 91. 1. Review of the facility's Medication Error policy, dated 2024, showed: -The facility shall ensure medications will be administered according the physician orders and in accordance with accepted standards and principles which apply to professionals providing services; -Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to allow sanitized kitchenware to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. This includes three additional kitchenettes. Facility staff also failed to maintain the kitchen ceiling free from flaking paint and dry wall tape to prevent potential food contamination. The facility census was 86. 1. Review of the facility's Dietary Cleaning Procedure policy, undated, showed staff are instructed as follows: -Keep floor of kitchen free of debris; -Wet or damp dishes or tableware will be allowed to dry completely before setting table or using; -Staff will use a clean as you go technique to keep the facility and neighborhood kitchen areas clean, functional and attractive. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain personal medical information in a manner to protect seven residents' privacy (Residents #22, #68, #244, #245, #247, #345 and #500). The facility census was 86. 1. Review of the facility's Notice of Privacy Practices Policy, undated, directed staff as follows: -This facility is required by the privacy regulations issued in the Health Insurance Portability and Accountability Act of 1996 (HIPPA) to maintain the privacy of each of our elder's medical information and to provide elders with notice of the facility legal duties and privacy practices with respect to each elder's information. Protecting the confidentiality of each elder's personal information has been, and always will be, a top priority for this facility; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel eight residents (Resident #1, #15, #17, #49, #56, #65, #77, and #80) in wheelchairs in a manner to prevent accidents, failed to properly store razors/sharps for four residents (Resident #47, #54, #56 #73), failed to properly store medications for one resident (Resident #61), failed to lock medication/treatment cart when not in eyesight, and failed to store medications properly when they left insulin pens unattended on top of medication carts. The facility census was 86. 1. Review of the facility's Wheelchair Mobility policy, dated 2023, showed staff were directed to do the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure a medication error rate of less than 5%. Out of 37 opportunities, five errors occurred, with two residents (Resident #1 and #31) resulting in a medication error rate of 13.51%. The facility census was 86. 1. Review of the facility's Medication Administration Schedule policy, revised [DATE], showed routine schedule for medications administration was every morning from 8:00-9:00 A.M. Review of the Medication Administration policy, undated, showed staff were directed to do the following: -Provide privacy; -Compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, form, dose, route, and time; -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician; -Identify expiration date. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to provide appropriate catheter care, hand hygiene, and glove changes for two resident's (Resident #5, and #28), and failed to prevent one resident's (Resident #28) catheter tubing from touching the ground. 1. Review of the facility's Catheter Care policy, showed staff are directed as follows: -Catheter care will be performed every shift as needed by nursing personnel; -Ensure drainage bag is located below the level of the bladder to discourage backflow of urine; -Document care and report any concerns noted to the nurse on duty. Female: -Use a new part of the cloth or different cloth for each side; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of the residents by failing to keep the call lights within reach for four residents (Resident #8, #9, #10 and #80). The facility census was 86. 1. Review of facility's Call Light: accessibility and timely responses Policy, undated, showed the policy instructed staff as follows: -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; -Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident #31, and #66) received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice by failing to provide ongoing assessments of the resident's condition, and monitoring for complications before and after dialysis treatments, and provide ongoing communication and collaboration with the dialysis clinic. The facility census was 86. 1. Review of the facility's Hemodialysis policy, revised February 2023, showed staff are directed as follows: [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to store medications in a safe and effective manner for four sampled medication carts. The facility census was 86. 1. Review of the facility's Storage of Medications policy, undated, showed staff were directed as follows: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication room according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. 2. Observation on 10/23/23 at 10:41 A.M., showed the neighborhood [NAME] and Clark's medication cart contained the following: -One loose half white pill; -One loose white pill; -One loose red pill. 3. [...]