Neighbors Health Center

In the surveyor’s words

From the most serious findings on record at Neighbors Health Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 20, 2025

  Based on interview and record review the facility failed to keep a resident free from physical abuse. This applies to 4 of 6 residents (R1, R2, R3 & R4) reviewed for abuse in the sample of 41. This failure resulted in R1 being sent to the local hospital and diagnosed with a posterior head laceration and initial CTH with acute SDH (computed tomography with acute subdural hematoma) of the left frontal, parietal, and temporal lobes. The findings include: 1. The facility's final report to the state surveying agency regional office dated December 20, 2023, shows, It was immediately reported to Administrator (V1) that R1 sustained a fall with injury while in the memory care dining room. […]

• Actual harm, isolatedF684Jan 25, 2023

  Based on observation, interview, and record review the facility failed to monitor blood glucose for a diabetic resident for 1(R1) of 3 reviewed for diabetic care in the sample of 9. Due to this failure, R1's blood glucose level decreased to an abnormally low level of to 20 mg (milligrams)/dL (deciliter) and required being sent to the emergency room . The findings include: On 1/25/23 at 12:20 PM, R1 was sitting up in his wheelchair in therapy. R1 stated, They were evidently not checking my sugars because my sugar dropped too low, and I ended up at the hospital. I didn't know I was in the ambulance. […]

• No harm, potential for more than minimal, widespreadF761Sep 5, 2024

  Based on observation, interview, and record review the facility failed to securely store medications. This applies to 1 of 6 medication carts reviewed for medication storage. The findings include: On 9/5/24 at 10:45 AM, V3 (Assistant Director of Nursing) was assisting this surveyor during medication storage review. V3 said she had to find the nurse on the hall to get the keys to the cart and walked away from the surveyor. When V3 returned to the medication cart she opened the narcotic count binder that was laying on the right side of the cart and the nurse's keys were laying just under the binder cover. V3 removed the keys from the binder and proceeded to open the medication cart. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2022

  Based on observation, interview, and record review the facility failed to ensure meal prep and service was done in a sanitary manner. This has the potential to affect all 100 residents in the facility. The findings include: The Resident Census and Conditions of Residents form CMS-672 shows on 2/14/22 the facility census was 100. On 2/14/22 the noon meal service was observed from 11:00 AM to 1:35 PM. Upon the surveyor entering the kitchen at 11:00 AM, V9 (Dietary Manager) had no hair net on. V9 with no hair net on, made pureed food consisting of chicken, asparagus, and tortellini. V9 continued with no hair net on and plated and served residents meals trays at the steam table on the serving line. At 12:50 PM, V9 stepped away from the serving line and returned with a hair net on. […]

• No harm, potential for more than minimal, widespreadF880Apr 28, 2021

  Based on observation, interview, and record review the facility staff failed to wear a surgical face mask covering their nose to prevent and spread of COVID-19. The facility failed to ensure staff wore personal protective equipment (PPE) and failed to disinfect resident care equipment after coming into contact with the resident on contact isolation (R31). This applies to all 84 residents residing in the facility. The findings include: The Resident Census and Conditions of Residents (Form CMS-671) dated 4/26/21 shows that there are 84 residents residing in the facility. 1. On 4/26/21 at 11:35 AM, V13 (Cook) was in the kitchen preparing beef. V13 had a fabric face mask on and it was below his nose. […]