Neighbors - East Neighborhood (The)

In the surveyor’s words

From the most serious findings on record at Neighbors - East Neighborhood (The), in the surveyor’s own words.

• Actual harm, isolatedF689Feb 13, 2024

  Based on record review and interview, the facility did not provide adequate supervision to prevent accidents for 1 of 5 residents (R1) reviewed for supervision with showers and monitoring of water temperatures. R1 had a known history of taking long showers independently, when assessed to require maximum assistance with showers. The facility did not address this behavior in a plan of care. The facility was aware of fluctuating water temperatures on R1's household. The water temperatures were not monitored. R1 entered the shower independently. without assistance, on 1/30/24 and suffered actual harm sustaining second and third degree burns. Findings include: Facility Water Management Plan approval date of 07/17/23 and effective date of 07/17/23. 1. DESCRIPTION OF THE WATER SYSTEM: C. […]

• No harm, potential for more than minimal, widespreadF887Jan 7, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF880Sep 26, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF880Aug 30, 2023

  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. […]

• No harm, potential for more than minimal, patternF880Jan 7, 2026

  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. […]