Neighborhoods Rehabilitation and Skilled Nursing B

In the surveyor’s words

From the most serious findings on record at Neighborhoods Rehabilitation and Skilled Nursing B, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 5, 2025

  Based on interview and record review, facility staff failed to monitor one resident (Resident #1) at least every two-hours per facility policy and based on resident needs. Staff did not monitor the resident between the hours of 11:00 P.M. and 3:10 A.M. Resident #1 was found entrapped in the bedrail, face down in the mattress, unresponsive, and he/she passed away. The facility census was 89.The administrator was notified on [DATE] of Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. The Administrator immediately terminated Licensed Practical Nurse (LPN) C, suspended Certified Nursing Assistant (CNA) B pending the results of the investigation, conducted an investigation, and in-serviced all staff on rounding on [DATE]. […]

• Immediate jeopardy, isolatedF700Sep 5, 2025

  Based on observation, interview and record review, facility staff failed to re-assess bedrail use after a significant change in condition per policy for one resident (Resident #1). Resident #1 was found entrapped in the bedrail, found face down in the mattress and unresponsive, resulting in his/her death. The facility census was 89. The administrator was notified on 09/03/2025 of an Immediate Jeopardy which began on 08/26/2025. The IJ was removed on 09/03/2025, as confirmed by surveyor onsite verification. 1. Review of the facility's Proper Use of Bed Rails policy, undated, showed staff are to ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, or depth. […]

• Immediate jeopardy, isolatedF678Mar 31, 2025

  Based on interview and record review, facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for resident (Resident #1) with a signed full code physician order. The facility census is 86. The administrator was notified on [DATE] of past noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. Administration immediately in-serviced nursing staff on CPR, code status, and two-way radio communication policies. The IJ was corrected on [DATE]. Review of the facility's CPR policy, undated and reviewed/revised on [DATE], directed staff to adhere to residents' rights to formulate advance directives. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. […]

• Actual harm, isolatedF600Jul 6, 2023

  Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect when they failed to ensure the facility van driver properly secure the required safety belt around one resident (Resident #1) while the facility driver transported the resident in the facility van. As a result, the resident's wheelchair tipped upside down on top of him/her and the resident sustained lacerations to his/her head, ear, and arm when the driver made a sharp turn. The facility census was 83. The administrator was notified on 6/27/23 of Past Non-Compliance which occurred on 6/14/23. On 6/14/23, the administrator identified Driver A neglected to safely secure a resident's wheelchair in the facility van during a transport which resulted in injury to the resident. […]

• No harm, potential for more than minimal, widespreadF761Jan 23, 2026

  Based on observation, interview, and record review, facility staff failed to label eye drops and nasal sprays in accordance with professional standards and failed to destroy expired medications for three medication carts and one medication room. The facility census was 88.1. Review of the facility's Medication Storage policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of eye drops or nasal sprays. Review of the facility's Administration of Eye Drops policy, dated 2001, showed the policy directed staff to label new bottles with date opened and follow facility policy or manufacturer's instructions for when to discard and replace the bottle.Review of the facility's Administration of Nasal Spray Administration policy, dated 2025, showed the… […]