Neighbors - East Neighborhood (the)

Based 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. Findings include:Surveyor was provided separate policies titled Antibiotic Stewardship, Infection Surveillance, Influenza Prevention, Influenza Vaccination, Pneumococcal Vaccine, and the Pandemic Plan. There was no policy for COVID 19 vaccination or mention of COVID 19 vaccination of residents or staff in any of the policies. Code of Federal Regulations S483.80(d)(3) COVID-19 immunizations states in part: The LTC (long term care) facility must develop and implement policies and procedures to ensure all the following(ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: The purpose of the Laundry is to collect, launder, and return linens and clothing to maintain adequate supplies of clean, sanitary linens for Health Center use. Procedure: Resident Laundry is completed on bath day or as needed. AM/PM staff and homemakers should do all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.The facility policy titled, Bed Hold Policy for Medical Assistance Residents, last reviewed on 10/25/25 states in part, Beds shall be held for fifteen (15) days for the residents receiving Medical Assistance (MA) while on a hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. [R7] doesn't want to work toward dentures.On 08/08/23, a physician order for R7 requesting a dental appointment. On 10/18/23, date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Minimum Data Set (MDS) dated [DATE] a quarterly assessment documented a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe impaired cognition. R1 has fluctuating behaviors of delirium with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: Example 1 Facility's policy titled Infection Surveillance version 2.2, documented, in part: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated infections, to guide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: Example 1 R32 was admitted to the facility on [DATE], with diagnoses of Alzheimer's and dementia. Quarterly minimum data set assessment (MDS) dated [DATE] indicated R32 required a mechanically altered diet and is dependent on others for meal assist. On 09/24/24 at 11:44 AM, Surveyor observed Certified Nursing Assistant (CNA) F standing over R32 and using the spoon to clean food from around R32's mouth and then used R32's clothing protector to clean mouth instead of napkin. This observation occurred multiple times during the lunch observation of CNA F with R32. Example 2 R6 was admitted to the facility on [DATE] with diagnoses of Lewy Body dementia and memory deficit following cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Surveyor asked about the error in MDS coding stating the PASARR level 2 was not completed, when Surveyor observed that it was completed. SW C stated, It…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Surveyor also observed R3's portable oxygen tank on his wheelchair; the tubing connected to the portable oxygen was not dated. R3's physician orders, dated 1/29/24, state in part Oxygen: Change oxygen tubing every 5 days. On 09/25/24 at 10:53…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Example 1 On 08/30/23, Surveyor observed Certified Nursing Assistant (CNA) G wrapping silverware in the Eastbrook dining room. Surveyor also noted CNA G to have 2 open red areas on their top left forearm. One area was about the size of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The FDA Food Code 2022 document 2-402.11 Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 08/30/23 at 7:20 AM, Surveyor observed CNA E serving breakfast to residents in the kitchenette. Surveyor asked CNA E if you are supposed to wear a hairnet when you are serving breakfast from this kitchenette. CNA E replied, Oh yeah, and walked around the counter, opened a drawer, pulled out a hairnet and put it on. On 08/30/23 at 9:30 AM, Surveyor interviewed Culinary Mentor (CM) F regarding the use of hairnets in the kitchenette. CM F replied,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.