Neighbors - East Neighborhood (the)

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 3 of 3 residents at risk for elopement received adequate supervision and assistance devices to prevent accidents. R3 is at risk for elopement and did not have a wander guard in place as ordered. R1 eloped out of facility on [DATE]. R1 had wander guard attached to the front bottom metal bar of R1's walker. R2 had wander guard attached to the wheelchair metal frame. Facility staff did not follow recommendations from the manufacturer's instructions.

Inspectors wroteBased on interview and record review, the facility did not maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status to staff. This has the potential to affect all 45 residents. The facility did not provide education to all staff for the COVID 19 vaccine. Facility did not develop and implement policies and procedures regarding the COVID 19 vaccine immunization.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. Housekeeping did not use any type of clothing barrier (e.g., apron) when sorting and washing dirty laundry. This practice had the potential to affect all 16 residents residing in the same household. Improper hand hygiene was observed during catheter care and personal care for R5 and R29. The facility policy, titled Laundry Duties, last reviewed 2/5/25, states in part: Policy: The Neighbors of [NAME] County provides laundry services to its residents. This includes both personal clothing and facility linens. Purpose: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives received notice of bed-hold policy indicating specific reason for transfer or discharge, received notice before transfer or discharge indicating reserve payment, and/or did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman Notification for 2 of 3 residents (R8 and R16).-Facility did not provide a transfer notice form for R16's hospitalizations on 07/09/25, 07/19/25, and 07/23/25.-Facility did not provide specific reason for transfer for R8's hospitalization on 12/06/25.-Facility did not have notification of the daily bed rate on the bed hold policy forms for R8's hospitalization on 12/06/25 or R16's hospitalizations on 07/09/25, 07/19/25, and 07/23/25.-Facility did not notify Ombudsman of R16's hospitalization on 07/19/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure follow up dental care for 1 (R7) of 1 resident reviewed for dental care. R7 complained of tooth pain and requested to see a dentist to have remaining teeth pulled due to broken teeth causing pain during eating. The facility did not document the follow up or extenuating circumstances that led to the delay. Evidenced by: R7 was admitted to the facility on [DATE]. R7's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 11/11/25, indicates R7's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Surveyor reviewed R7's dental progress notes, physician orders, and an email chain pertaining to dental needs: On 07/18/23, progress note states, Specialty care referral form completed to VA for [R7]. [R7] asking to have the rest of his teeth pulled. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 1 of 3 residents (R) reviewed. (R1)On 10/01/25, R1 alleged was sexually assaulted by a man. The facility nursing staff did not complete a full body skin assessment to thoroughly investigate the allegation. Facility's policy titled Reporting & Investigating Resident Rights Violations with revised date of 12/15/24, read in part: Assess the Effect on the Resident: Nursing supervisor immediately completes a body assessment and documents findings. R1 was admitted to the facility on [DATE]. R1's current diagnoses include dementia with anxiety, generalized anxiety disorder, dementia with mood disturbance, type 2 diabetes mellitus, chronic kidney disease, and restless legs syndrome. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 43 residents in the facility. The facility did not have an adequate surveillance and infection control program in place for tracking and monitoring infection and communicable disease for staff and residents. Staff did not sanitize lift for R11 after resident use. Staff did not sanitize hands during dressing change for R24. Enhanced Barrier Precautions were not put in place for R24, R18 and R26. This is evidenced by: [...]

Inspectors wroteBased on observation and record review, the facility did not ensure residents (R) were treated with dignity and respect and cared for in a manner to enhance their quality of life. Facility staff used clothing protectors and edge of spoon to wipe resident's face and stood over R32 and R6 while assisting them to eat.

Inspectors wroteBased on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessment for 1 of 1 residents (R) reviewed for Preadmission Screening and Resident Review (PASARR) screen (R37). R37's MDS assessment is coded in error stating that a PASARR level 2 screen had not been completed when it was. This is evidenced by: R37 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia and anxiety. Review of R37's medical record found a PASARR level 2 screen was completed, dated 05/06/24. R37's admission MDS assessment, dated 05/14/24, and significant change MDS assessment, dated 07/26/24, indicated for question A1500 that no PASARR level 2 had been completed. On 09/26/24 at 11:00 AM, Surveyor interviewed Social Worker (SW) C, who completed the MDS Section A1500 on R37's admission and significant change MDS. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 1 resident (R) R3, reviewed for respiratory care was provided care consistent with professional standards of practice. R3 requires continuous oxygen and has a physician's order to change oxygen tubing every 5 days. This was not changed as ordered. This is evidenced by: Facility Policy entitled OXYGEN ADMINISTRATION last revised 03/01/24 states in part 2. Oxygen tubing, masks, etc. c. Are to be changed every 5 days and as needed per the E-MAR/TAR. R3 was admitted to the facility in 2023 and has diagnoses that include chronic obstructive pulmonary disease and atherosclerotic heart disease. R3 utilizes continuous oxygen. On 09/24/24 at 9:14 AM, Surveyor observed R3's oxygen tubing connected to the concentrator in his bedroom. The oxygen tubing is dated 9/1. [...]

Inspectors wroteBased on record review and interview, the facility did not provide adequate supervision to prevent accidents for 1 of 5 residents (R1) reviewed for supervision with showers and monitoring of water temperatures. R1 had a known history of taking long showers independently, when assessed to require maximum assistance with showers. The facility did not address this behavior in a plan of care. The facility was aware of fluctuating water temperatures on R1's household. The water temperatures were not monitored. R1 entered the shower independently. without assistance, on 1/30/24 and suffered actual harm sustaining second and third degree burns.

Inspectors wroteBased on observations and interviews, the facility did not implement appropriate infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections. Staff observed with open sores assisting residents with meals and prepping silverware. Staff observed washing hands and turning off the faucet with clean hands. No hand hygiene was offered for residents before meals on 2 of the 3 households. This affected 30 of 46 residents (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31, R14, R1, R12, R43, R27, R25, R14, R25, R36, R8, R6, R41, R16, R24, R197, R30, and R26). Staff touching straws with bare hands. This affected 13 residents (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31). No hand hygiene with glove change during medication pass for R97.

Inspectors wroteBased on observation, staff interview and record review, the facility did not follow proper food handling practice. This practice had the potential to affect 16 of 46 residents (R14, R25, R45, R36, R12, R8, R6, R27, R41, R16, R1, R24, R197, R28, R30, R26) residing in the facility. Certified Nursing Assistant (CNA) E did not wear a hairnet while serving breakfast.