Neilson Place

In the surveyor’s words

From the most serious findings on record at Neilson Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 27, 2024

  Based on interview and document review the facility failed to immediately identify code status and act on resident wishes for 1 of 3 residents (R1) reviewed for resuscitation status. This resulted in an immediate jeopardy for R1 when staff initiated cardiopulmonary resuscitation (CPR) against R1's wishes. The IJ began on [DATE], at approximately 5:40 p.m. when R1 was found by a nursing assistant (NA)-A in the common area of the unit. R1 was pale, lips blue and unable to speak. R1 was administered the Heimlich Maneuver, CPR was initiated and was sent to the hospital where she subsequently required mechanically assisted ventilation. The IJ was identified on [DATE], and the administrator was notified of the IJ on [DATE], at 11:13 a.m. […]

• Actual harm, isolatedF689Dec 9, 2025

  Based on observation, interview, and document review, the facility failed to ensure care planned fall interventions were implemented for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm for R1 who fell and sustained a fracture requiring surgical repair. The facility implemented corrective action prior to the start of survey, and this is issued in past noncompliance. R1's Resident Face Sheet indicated she was admitted to the facility on [DATE] and re-admitted , following hospitalization, on 11/13/25. R1's diagnosis included displaced fracture of right femur. Alzheimer's disease, dementia, history of sacral fracture and failure to thrive. […]

• Actual harm, isolatedF603Jul 2, 2025

  Based on observation, interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for use of electric wheelchairs in the community was free from involuntary seclusion. This resulted in actual psychosocial harm for R1 when the facility took away her personal mobile equipment (power wheelchair), which restricted R1's access to her community (including family), causing increased depressive symptoms, isolation and withdrawal from usual activities. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included diabetes, arthritis, right above the knee amputation, post-traumatic stress disorder, depression and anxiety. […]

• Actual harm, isolatedF689Dec 20, 2024

  Based on interview and document review the facility failed to follow care planned intervention for the use of a gait belt for 1 of 3 residents (R1) reviewed. This resulted in actual harm when R1 fell while ambulating with staff assistance and sustained bilateral sacral fractures (a break in the bone at the back of the pelvis). The deficient practice was corrected prior to the start of the survey therefore, was issued at past non-compliance. Findings include: R1's Resident Face Sheet identified an admitted [DATE] and a latest return date of 12/16/24. R1's diagnosis included osteoarthritis, age related osteoporosis and impaired mobility. R1's care plan dated 10/25/22, identified a self care deficit due to morbid obesity and pain in right knee. […]

• Actual harm, isolatedF686Feb 29, 2024

  Based on observation, interview and document review the facility failed monitor and develop and implement interventions to reduce the risk of pressure ulcers for 2 of 3 residents (R1,R4) reviewed. This resulted in actual harm to R1 who developed new and worsening pressure ulcers. Findings include: R1 Admission Observation dated 1/2/24, identified bruises and pressure sores. The observation did not identify location, size or stage of pressure sores. R1's Skin Risk assessment dated [DATE] indicated a Braden Scale for predicting pressure ulcer risk identifed a score of 13, inidcating he was at moderate risk for skin breakdown. R1's Physician Order Report dated 1/2/24 through 2/29/24, identified an order dated 1/2/24, that indicated: weekly skin check. […]