Good Neighbor Home

In the surveyor’s words

From the most serious findings on record at Good Neighbor Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF622Aug 2, 2023

  Based on clinical record review, staff interview, family interview, and the chief of police interview, the facility failed to provide a safe discharge for a resident newly admitted from the emergency room (ED) to the facility on [DATE] after sustaining a fall at work which resulted in a fractured right cuboid bone and calcaneal fracture (ankle). Staff received a verbal telephone order okaying the admission of this resident. The facility accepted the resident into the facility, began the admission process, assisted the resident to a room, provided toilet use assistance, and performed a skin assessment of the gluteal area. […]

• Actual harm, isolatedF689Oct 10, 2025

  Based on observation, clinical record review, staff interview and facility policy review the facility failed to maintain the safety and security for 2 of 5 residents identified as a fall risk (Residents #1 and #3). Resident #1 had a prior history of falls from her recliner. After Resident #1's fall on 5/27/25, the facility put the Intervention in place to have her recliner unplugged. On 6/7/25, the staff observed Resident #1 during the room rounds. One staff member reported seeing Resident #1 in her recliner with her feet elevated. At approximately 3:19 PM, the staff found Resident #1 on the floor with her footrest in an upright position. […]

• Actual harm, isolatedF550Aug 2, 2023

  Based on clinical record review, observations, pictures, staff, resident, and family interviews and review of the faculties Residents' Rights form the facility failed to treat 1 resident with dignity and respect during a discharge from the facility. (Resident #1) The facility identified a census of 94 residents: Findings include: An X-ray report from a local hospital for Resident #1 dated 6.6.23 at 7:54 a.m. included the following: a. A mildly comminuted cuboid fracture. b. A mildly displaced fracture of the anterior process of the calcaneus. A Discharge Instructions form from the hospital dated 6.6.23 at 9:07 a.m. indicated the resident's diagnosis included: heel pain, morbid obesity, and a right foot injury. The physician orders included the following: a. […]

• No harm, potential for more than minimal, patternF725Oct 10, 2025

  Based on observation, clinical record review, video footage, staff interview, and family interview the facility failed to maintain an appropriate number of staff to meet the individual needs of residents who resided in a Chronic Confusion or Dementing Illness unit (CCDI). The facility reported 20 residents resided in the CCDI unit. The facility identified a census of 99 residents. Findings include:During an interview 10/8/25 at a time unknown Staff D, Registered Nurse (RN) indicated of the 20 residents who resided in [NAME] Place and/or the Chronic Confusion or Dementing Illness unit (CCDI) unit seven (7) residents required one (1) staff assistance and 1 resident required two (2) staff assistance with activities of daily living (ADL's) Resident #3's MDS assessments dated 7/11/25 and… […]

• No harm, potential for more than minimal, patternF880Aug 15, 2024

  Based on observation, Center for Disease Control and Prevention (CDC) COVID 19 Guidelines, and staff interview, the facility failed to ensure housekeeping staff wore appropriate personnel protective equipment (PPE) to prevent the spread of COVID 19 infection during a COVID 19 outbreak within the facility. The facility reported a census of 98 residents. Findings include: During entrance to the facility on [DATE] at approximately 9:00 AM the facility posted a Visitor/Team Stop Sign on the main entrance door directing to please postpone entry to the facility if you have any of the following symptoms that are new or worsening: fever, cough, congestion, chills, headache, body aches, sore throat, runny nose, fatigue, diarrhea, nausea/vomiting, new loss of taste or smell. […]