Neighbors - West Neighborhood (The)

In the surveyor’s words

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

• Actual harm, isolatedF600Dec 13, 2023

  Based on record review and interviews, the facility did not implement interventions to protect other residents from abuse by a resident (R) (R97) with a history of aggressive behaviors which resulted in a fall with fracture for 1 of 1 resident (R28) reviewed for falls. Findings include: The facility policy entitled Reporting & Investigating Resident Rights Violations, approved on: March 9, 2007, reads in part It is the intent and desire of [Then [sic] Neighbors of Dunn County] to provide resident care in a safe and professional manner and to avoid allegations of resident abuse or other misconduct. R97 was admitted [DATE] and has diagnoses that include Alzheimer's, depression, and anxiety disorder. Surveyor reviewed R97's Minimum Data Set (MDS) quarterly assessment dated [DATE]. […]

• No harm, potential for more than minimal, patternF880Dec 13, 2023

  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. […]

• No harm, potential for more than minimal, isolatedF605Mar 19, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF689Mar 19, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF697Mar 19, 2026

  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. […]