Neighbors - West Neighborhood (the)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Every 4 Hours - PRN, PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6 - Open ended date. Review of R15's medication administration record (MAR) revealed R15 used lorazepam 0.25mg for…

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 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. The program identifies the factors that place residents at risk for falls, promotes proactive healthcare practices for resident care planning, and identifies the main components of an effective fall prevention program. These components are fall risk assessment,…

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 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. Upon admission, all residents will be assessed for the presence of pain. The appropriate pain scale will be used to rate the pain. The health care team will collaborate with resident and…

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 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. Findings: Facility policy titled, Hand Washing, Hand Hygiene reviewed 9/19/2025 stated in part: .Examples of hand hygiene moments: Before touching a resident, before clean/aseptic procedures, after body fluid exposure risk, after touching a resident, after touching a resident's surroundings, before and after utilizing gloves .Example 1 R5 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated R5 was cognitively intact. R5 had a diagnosis of acute cystitis with sepsis (a medical emergency where a bladder infection spreads into the bloodstream, causing a severe systemic response). On…

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 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. AM's until healed (pressure sores, venous stasis, arterial, diabetic ulcers, open surgical wound) R30 was admitted to the facility on [DATE] and has current diagnoses of open wound left lower leg, osteoporosis 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, 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: Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device,…

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 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) Findings include: A facility policy specific to resident hand hygiene was requested. Surveyor received the facility policy titled, Hand Washing, Hand Hygiene, not dated; it stated in part, The facility will utilize hand hygiene practices that assist in the decrease of infectious disease transmittal. On 12/12/23 at 11:38 AM, Surveyor observed coffee, water, and milk being served to residents seated in the dining room for lunch. No hand hygiene was given to residents R24, R14, R40, R12, R8, R36, R6, and R21. On 12/12/23 at 11:51 AM, Surveyor observed that no hand hygiene had been offered to residents R24, R14, R40, R12, R8, R36, R6, and R21 yet. On 12/12/23 at 11:53 AM,…

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 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. Findings include: The facility policy entitled, Reporting & Investigating Resident Rights Violations Policy and Procedure, approved on March 9, 2007, reads in part Residents may be the intended or unintended recipients of abuse or the cause of abuse resident-to-resident abuse must also be reported immediately. R97 was admitted [DATE] and has diagnoses that include Alzheimer's, depression, anxiety…

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 interviews and record review, the facility did not thoroughly investigate an incident of potential resident to resident abuse for 1 of 1 incident reviewed. Findings include: R97 was admitted [DATE] and has diagnosis that include Alzheimer's, depression, anxiety disorder and hypertensive heart disease. R97's Minimum Data Set (MDS) assessment, indicated that R97 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R97 has severe impairment. R28 was admitted to the facility on [DATE] and has diagnoses that include neurocognitive disorder with Lewy bodies, neuroleptic induced Parkinson, dementia, generalized anxiety disorder, and is unsteady on their feet. R28's Minimum Data Set (MDS) assessment indicated that R28 has a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R28 has severe impairment. On 12/13/23, Surveyor reviewed an incident report for a fall that happened on 08/04/23. Creator of the report is Registered Nurse (RN) G. The chronological…

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 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) Findings include: R22 was admitted to the facility on [DATE] with the following diagnoses, in part: paraplegia, chronic kidney disease stage 2, neuromuscular dysfunction of bladder, and retention of urine. On 12/11/23 at 11:53 AM, Surveyor observed R22 in a chair in her room with a urinary drainage bag hanging from the side of the chair. R22 said they had a suprapubic catheter, but it fell out and could not be re-inserted. R22 stated they put a regular Foley catheter in until they can get in to the urologist to have the suprapubic catheter replaced. Surveyor reviewed R22's medical record and identified R22 had a suprapubic catheter placed in June of 2023. Surveyor reviewed R22's comprehensive care plan and identified a bowel and bladder care plan that was initiated on 09/28/22.…

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 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) Findings include: According to the American Psychiatric Association patients with dementia who show adequate response of behavioral/psychological symptoms to treatment with an antipsychotic drug, an attempt to taper and withdraw the drug should be made within 4 months of initiation, unless the patient experienced a recurrence of symptoms with prior attempts at tapering of antipsychotic medication. (The American Journal of Psychiatry, May 2016) R26 was admitted to the facility on [DATE] with the following diagnoses, in part: unspecified dementia with mood disturbance and anxiety, unspecified mood disorder, major depressive disorder single episode, anxiety disorder, dementia with psychotic disturbance, visual hallucinations. Record review identified…

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, 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. On 12/13/23 at 8:14 AM, Surveyor observed Homemaker C sitting next to resident R31 giving them bites of their breakfast again. On 12/13/23 at 8:27 AM, Surveyor observed Homemaker C give R27 a bite of their breakfast. On 12/13/23 at 11:38 AM, Surveyor interviewed Director of Nursing (DON) B and asked if they employed…

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.