Neilson Place

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food service equipment used in 3 of 4 facility kitchenettes ([NAME], Strawberry and Elderberry) were kept in a clean and sanitary condition to prevent potential food-borne illness. This had the potential to affect 86 of 87 residents, visitors and staff who consumed food prepared in the kitchenettes. In addition, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination in 1 of 4 freezers (Strawberry Unit) used in the facility's kitchenettes. This had the potential to affect all 19 residents who resided on the Strawberry unit and could potentially consume the items.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff utilized the appropriate personal protective equipment (PPE) during high contact cares for 3 of 4 residents (R66, R67, R49) reviewed for enhanced barrier precautions. In addition, the facility failed to implement timely airborne precautions for 1 of 2 residents (R16) reviewed for transmission-based precautions. ENHANCED BARRIER PRECAUTIONS: R66 R66's comprehensive MDS dated [DATE], identified R66 had severe cognitive impairment and diagnoses included traumatic brain dysfunction, quadriplegia and seizure disorder. R66 used a feeding tube. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure clinical justification and ensure non-pharmacological interventions were utilized prior to initiation of an antipsychotic for 1 of 6 (R6) residents reviewed for psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a significant change in status assessment (SCSA) was completed within required timeframe to help facilitate timely person-centered care planning for 1 of 3 residents (R21) reviewed for Minimum Data Set (MDS) accuracy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure foot pedals were removed from the wheelchair as directed by the care plan for 2 of 3 residents (R21, R6) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e.,toileting assistance and/or nail care) were offered and/or completed for 2 of 3 residents (R63, R46) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to ambulate residents as directed for 1 of 1 resident (R21) reviewed for mobility decline.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents with side rails were comprehensively assessed prior to use/and or reassessed for appropriate continued use for 2 of 3 residents (R6, R63) reviewed who had side rails.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure care planned fall interventions were implemented for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm for R1 who fell and sustained a fracture requiring surgical repair. The facility implemented corrective action prior to the start of survey, and this is issued in past noncompliance. R1's Resident Face Sheet indicated she was admitted to the facility on [DATE] and re-admitted , following hospitalization, on 11/13/25. R1's diagnosis included displaced fracture of right femur. Alzheimer's disease, dementia, history of sacral fracture and failure to thrive. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was independent with bed mobility, sit to stand and required supervision for ambulation. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for use of electric wheelchairs in the community was free from involuntary seclusion. This resulted in actual psychosocial harm for R1 when the facility took away her personal mobile equipment (power wheelchair), which restricted R1's access to her community (including family), causing increased depressive symptoms, isolation and withdrawal from usual activities.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure respect and dignity for 1 of 3 residents (R1) reviewed when her personal power chair was removed from her room and use without her consent.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure cleaning of shared glucometers between patient use for 3 of 3 residents (R3, R4, R5) reviewed for infection control.

Inspectors wroteBased on interview and document review the facility failed to develop and implement care planned interventions to address refusal of cares for 1 of 3 residents (R1) reviewed for deteriorating skin condition.

Inspectors wroteBased on interview and document review the facility failed to ensure toileting and hygiene tasks were performed for 1 of 3 (R1) residents reviewed resulting in worsening skin condition that required physician ordered treatment.

Inspectors wroteBased on interview and document review the facility failed to follow care planned intervention for the use of a gait belt for 1 of 3 residents (R1) reviewed. This resulted in actual harm when R1 fell while ambulating with staff assistance and sustained bilateral sacral fractures (a break in the bone at the back of the pelvis). The deficient practice was corrected prior to the start of the survey therefore, was issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain clean and sanitary conditions of kitchen equipment and ensure hairnets were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 69 out of 69 residents that received food out of the kitchen or kitchenette.

Inspectors wroteEBP: R10's significant change MDS dated [DATE], identfiied R10 was cognitively intact and had diagnoses that included quadriplegia, type 2 diabetes, and neuromuscular dysfunction of bladder. R10 had a stage 4 pressure ulcer, a colostomy and an indwelling catheter and was receiving intravenous medications. R10's care plan revised 11/19/24, identified R10 had an infection to a sacral wound (a region located at the base of the spine in the pelvic area) wound and had a need for enhanced barrier precautions due to indwelling urinary catheter and chronic wound. The following interventions were identified: - Post signage on door or wall outside of resident room - PPE available immediately outside of resident room. Staff to wash their hands upon entering and leaving room. PPE to be doffed prior to leaving resident room. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide routine oral care and shaving assistance to 1 of 5 residents (R23) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and develop interventions to reduce or prevent continued weight loss for 1 of 1 resident (R30) reviewed for nutrition. We should also righ notification to he Dr at F580 . jsut need peices of it the record showing weight losss and interviews they should notify dr.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure required nurse staffing information was consistently posted on a daily basis. This had potential to affect all 72 residents, staff, and visitors who could wish to review this information.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or medical justification of use for 1 of 5 residents (R3) reviewed for unnecessary medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted and/or medical justification was provided to support ongoing use of an antipsychotic medication for1 of 5 residents (R3) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders and/or manufacturer guidelines for 2 of 6 residents (R23, R54) observed to receive medication during the survey. This resulted in a facility medication administration error rate of 6.9 percent (%).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the correct diet texture was served to 1 of 5 residents (R38) reviewed for pressure ulcers; and failed to accommodate dietary preferences of 1 of 1 resident (R58) reviewed for food choices.

Inspectors wroteBased on interview and document review, the facility failed to provide offer and provide risk vs benefits of receiving or declining immunizations per Center for Disease Control and Prevention (CDC) guidance for 1 of 5 residents (R38) reviewed for immunizations.

Inspectors wroteBased on interview and document review the facility failed to immediately identify code status and act on resident wishes for 1 of 3 residents (R1) reviewed for resuscitation status. This resulted in an immediate jeopardy for R1 when staff initiated cardiopulmonary resuscitation (CPR) against R1's wishes. The IJ began on [DATE], at approximately 5:40 p.m. when R1 was found by a nursing assistant (NA)-A in the common area of the unit. R1 was pale, lips blue and unable to speak. R1 was administered the Heimlich Maneuver, CPR was initiated and was sent to the hospital where she subsequently required mechanically assisted ventilation. The IJ was identified on [DATE], and the administrator was notified of the IJ on [DATE], at 11:13 a.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop a comprehensive care plan with person centered interventions for food seeking behaviors for 1 of 3 residents (R1) reviewed for behavioral health needs.

Inspectors wroteBased on observation, interview, and document review, the facility failed to obtain blood sugar checks and administer insulin timely, as ordered by physician, for 3 of 3 residents (R1, R2,R3) who had a diagnosis of diabetes.

Inspectors wroteBased on observation, interview and document review the facility failed monitor and develop and implement interventions to reduce the risk of pressure ulcers for 2 of 3 residents (R1,R4) reviewed. This resulted in actual harm to R1 who developed new and worsening pressure ulcers.

Inspectors wroteBased on observation, interview and document review the facility failed to assess, develop and implement interventions to reduce the risk for falls for 1 of 3 residents (R2) who had repeated falls with fractures. This resulted in actual harm for R2 who sustained a fractured nasal bone, fractured vertebrae and fractured rib. In addition, the facility failed to ensure safe use of mechanical lift devices for 3 of 3 residents (R2, R4, R5) reviewed. This resulted in further harm to R2 who fell from a EZ Lift Stand and sustained a broken clavicle (collarbone).

Inspectors wroteBased on interview and document review the facility failed to operationalize their policy for prompt resolution of grievances for 1 of 1 residents (R3) reviewed who filed a grievance related to care concerns in the facility.

Inspectors wroteBased on interview and document review the facility failed to report a fall from a mechanical stand that resulted in a broken clavicle (collarbone) to the state agency (SA) for 1 of 3 residents (R2) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to investigate a fall from a mechanical stand that resulted in a broken clavicle (collarbone) for 1 of 3 residents (R2) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to develop and implement interventions to prevent sexual abuse for 1 of 2 residents (R1) who was being sexually abused by another resident (R4).

Inspectors wroteBased on interview and document review the facility failed to timely report an allegation of sexual abuse to the state agency for 1 of 1 residents (R1) reviewed who was allegedly being abused by another resident (R4) in the facility.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an allegation of resident to resident sexual abuse for 1 of 1 residents (R1) who was being abused by another resident (R4).

Inspectors wroteBased on interview and document review, the facility failed to maintain an on-going infection control program, which included comprehensive surveillance of resident infections to identify and analyze possible patterns of infection in the facility, including identification of any patterns in residents, locations or pathogens in real time to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 69 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 1 of 1 resident (R7) who had food concerns.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R18) who utilized an indwelling catheter.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident current wishes for resuscitation status were accurately documented in the medical record for 2 of 27 residents (R8 and R25) reviewed for advanced directives.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R7) with visual and hearing impairments reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess, monitor, and provide necessary care 1 of 1 residents (R62) with a port-a-cath (an implanted device in the chest with direct access to a vein. It is used to administer medication or fluids that are unable to be taken by mouth or would harm a smaller peripheral vein, obtain blood tests, and measure central venous pressure) in the facility. R62 was at risk for injury or an infection.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure menus and individual resident food plans met the nutritional needs and preferences for 2 of 2 residents (R4 and R7) reviewed for food.

Inspectors wroteBased on observation and interview, the facility failed to ensure the posting of conspicuous signage of employee rights related to retaliation against the employee for reporting a suspected crime. This deficiency had the potential to affect all 69 residents currently residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of neglect to the state agency (SA) which had the potential to affect all residents who resided on the Elderberry unit of the facility.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate and allegation of neglect of care which had the potential to affect all residents who resided on the Elderberry unit of the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to perform root cause analysis and failed to provide staff education to reduce the risk for burns after 1 of 1 residents (R9) reviewed sustained a burn from a hot plate.