Neighbors - West Neighborhood (the)

Inspectors wroteBased on interview and record review, a resident's medication order was not limited to 14 days, and prescribing practitioner did not document the rationale for the extended time use or a specific duration for use for 1 of 3 sampled residents, (R) R15, reviewed for PRN (as needed) psychotropic medications. R15 was prescribed PRN lorazepam for anxiety on 02/27/2026; there was no rationale for extended use written and no specific duration for use. This is evidenced by: R15 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia with agitation and anxiety. R15's physician order dated 02/27/26 states: lorazepam - Schedule IVtablet; 0.5 mg; amt: 0.25mg; oral, Special Instructions: anxiety AEB (as evidenced by) frightened facial expr;verbal statements; Monitor response and consider alternative if ineffective. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 3 residents (R)(R11 and R35) reviewed. R11 and R35 had fallen; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions. This is evidenced by:Facility policy titled, Fall Risk Program, with a reviewed date of 03/04/25, states in part: POLICY: This program emphasizes assessment, identification, and intervention of resident falls, utilizing the least restrictive method to keep the resident safe. [...]

Inspectors wroteBased on interview and record review, the facility did not adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 1 resident (R)(R37) reviewed for pain management. R37 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management and non-pharmacological interventions were not implemented. This is evidenced by:Facility policy titled, Pain Management, with a reviewed date of 04/13/25, states in part: POLICY: Control of resident's pain is integral to the mission statement of the facility; Nursing will set a high priority on pain management and pain control. Pain will be assessed, treated, and evaluated for effectiveness whenever a resident experiences pain, whether chronic, breakthrough or acute. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (R5, R1, and R31) observed for proper hand hygiene during cares.

Inspectors wroteBased on interview and record review, the facility did not complete comprehensive weekly wound assessments for 1 of 2 residents (R)30 to ensure that residents receive treatment and care in accordance with professional standards of practice. R30 did not receive weekly measuring and comprehensive assessment of a skin injury. This is evidenced by: Review of the facility's policy titled: Wound management with the revised date of 12/03/21, read in part: .PURPOSE: To track, prevent, heal pressure ulcers/wounds according to standards of practice . PROCEDURE: .II. Assistant Clinical Mentors or licensed designee are responsible for weekly wound documentation. Review of the facility's Treatment Order form, read in part: 9. Weekly measurement and documentation (in Matrix under wound management tab) on Wed. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff did not initiate enhanced barrier precautions (EBP) for 1 of 3 residents observed (R21) with a wound. Facility staff did not wear personal protective equipment (PPE) for R30 who is on EBP or perform proper hand hygiene with cares. Facility staff used contaminated scissors to cut a wound dressing treatment and placed the cut dressing in R30's skin wound. Staff did not disinfect body sling after use for R11 and R21. Staff wore mask below nose when assisting one resident. This was evidenced by: Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions recommendations, dated 06/28/24, state in part: [...]

Inspectors wroteBased on record review and interviews, the facility did not implement interventions to protect other residents from abuse by a resident (R) (R97) with a history of aggressive behaviors which resulted in a fall with fracture for 1 of 1 resident (R28) reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; hand hygiene before meals was not offered for 10 of 43 residents (R) (R24, R14, R40, R12, R8, R36, R23, R197, R6, and R21)

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when a resident to resident abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 incidents with (R) R97 and R28 reviewed.

Inspectors wroteBased on interviews and record review, the facility did not thoroughly investigate an incident of potential resident to resident abuse for 1 of 1 incident reviewed.

Inspectors wroteBased on observation, interview and record review, the facility did not develop a comprehensive person-centered care plan that reflected resident care and needs related to urinary catheters for 1 of 3 residents (R) with catheters. (R22)

Inspectors wroteBased on interview and record review, the facility did not ensure a resident with a dementia diagnosis had a Gradual Dose Reduction (GDR) of psychotropic medications in the past year. This occurred for 1 of 5 residents (R) reviewed for unnecessary medications. (R26)

Inspectors wroteBased on observations, record review and interviews, the facility did not prevent untrained staff from feeding residents (R27 and R31) for 2 of 2 observations. This is evidenced by: Surveyor reviewed R31's medical record. Current diagnoses include dementia and Parkinson's disease. Review of Minimum Data Set (MDS) quarterly assessment with the review date of 10/06/23, documented R31 as being dependent on staff to assist with meals. Surveyor reviewed R27's medical record. Current diagnoses include non-traumatic brain dysfunction and dementia. Review of MDS quarterly assessment with the review date of 11/11/23, documented R27 needing partial to moderate assistance from staff with meals. On 12/13/23 at 8:12 AM, Surveyor observed Homemaker C give R31 a bite of their eggs. [...]