Neurorestorative

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were removed and discarded from the active supply in the medication storage room and 1 of 3 medication carts. The deficient practice had the potential to compromise the effectiveness of the medication. Findings include: On 02/25/2025 at 03:15 PM, an inspection of the facility's medication room with a Registered Nurse (RN) was completed. A box of disposable single-dose prefilled tip-lok syringes, each containing one 10 mcg/0.5 mL Hepatitis B vaccine for use from birth through [AGE] years of age was stored on the top shelf inside the medication refrigerator, with an expiration date of 02/17/2025. On 02/25/2025 at 03:27 PM, the RN confirmed the box of disposable single-dose prefilled tip-lok syringes each containing one 10 mcg/0.5 mL Hepatitis B vaccine for use from birth through [AGE] years of age was expired and should have been removed from the active supply to prevent administration. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure 1) justification for off-label (the practice of prescribing a drug for a different purpose other than the condition for which the drug was approved) antibiotic use was documented and prolonged antibiotic regimen was re-evaluated by the inter-disciplinary team (IDT) for 4 of 12 sampled residents (Residents 1, 7, 5 and 10) and 2) facility staff and providers were educated on the facility's antibiotic stewardship program (ASP). The deficient practice had the potential to place residents at risk for antimicrobial resistance. Findings include: Implementation of ASP Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral palsy and Lennox-Gastaut syndrome with status epilepticus. A physician's order dated 03/23/2024, documented to give Erythromycin Ethyl succinate reconstituted suspension 200 milligrams (mg) per 5 milliliters (ml) or 200 mg/5 ml, give 5 ml via gastrostomy tube (G-tube)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and document review, the facility failed to ensure the medication carts were locked when unattended. The deficient practice could have jeopardized the safety of both staff and residents, as unsecured medication carts increase the risk of unauthorized access to potent medications, medication errors, theft, or misuse, posing serious health hazards and compromising the overall well-being of individuals within the facility. Findings include: A facility policy titled Storage and Expiration of Medications, dated 01/01/2013 documented the facility should ensure the resident medications were locked. A pharmacy Consultation Report dated 01/25/2024, documented during the medication and cart review, it was noted the medication cart was left open and unattended. On 02/01/2024 at 3:09 PM, the medication cart in the Oasis hallway was parked, unlocked and unattended. An unsampled resident from Springs Hall wandered in the lobby and Oasis hallway. A Registered Nurse RN) assigned to the medication cart was not around, and there were no other staff in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were completed for 1) gastrostomy (GT) venting, 2) prophylactic antibiotics and 3) hypertension (HTN) with multiple antihypertensive medications for 3 of 14 sampled Residents (Resident 11, 13 and 22). The deficient practice had a potential for staff not to provide personalized care for residents. Findings include: 1) Resident 11 (R11) was admitted on [DATE], with diagnoses including pervasive developmental delay and GT dependent. On 01/30/2024 at 9:27 AM, in R11's room at the head of the bed on an intravenous (IV) pole, was a 30 milliliter (ml) open syringe with a tubing attachment. The 30 ml. syringe had no plunger and was attached to a plastic tubing to keep it above the level of the head of the resident. The syringe and the attached tubing contained residual tube feeding (TF) liquid. On 01/30/2024 at 9:39 AM, the registered nurse (RN) indicated the setup is for venting the resident's stomach after a TF…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and document reviews, the facility failed to ensure the timely execution or clarification of a physician's order for 1 of 14 sampled residents (Resident 18). The deficient practice could have had the potential for delayed treatment, hindered the completion of the investigation, and compromised the well-being and safety of the resident. Findings include: Resident 18 (R18) R18 was admitted on [DATE], with diagnoses including seizures, traumatic hemorrhage of the cerebrum with loss of consciousness, and tracheostomy status. On 01/31/2024 at 8:30 AM, R18 lay in bed in a supine position with eyes open, non-verbal, and non-interactive. The yearly history and physical dated 10/01/2023, documented R18, who unfortunately suffered a self-inflicted gunshot wound to the head and had significant medical complications following the incident. The neurologist documented R18 was non-verbal and non-ambulatory. mostly non-interactive, though R18 would turn head with close…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure splints were applied to hand contractures as ordered and documented for 1 sampled residents (Resident 2), and a physician order for a splint application was obtained for 1 sampled residents (Resident 6). The deficient practice could have the potential to exacerbate existing medical conditions, impede rehabilitation progress, and increase the risk of further complications, such as restricted joint mobility, muscle atrophy, prolonged recovery times, and diminished overall quality of life for the affected residents. Findings include: Resident # 2 (R2) R2 was admitted on [DATE], with diagnoses including hypoxic ischemic encephalopathy, tracheostomy status, and reduction deformity of the brain. A physician's order dated 11/16/2023, documented bilateral wrist and hand finger orthosis (WHFO) to be donned daily for up to 4 hours at 1000 (10:00 AM) and doffed at 1400 (2:00 PM) daily for tone management and contracture…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for gastrostomy (GT) venting for 1 of 14 sampled residents (Resident 11). The deficient practice has the potential for nursing interventions not being communicated with the physician and preventing the physician from being aware of the current status of the patient. Findings include: Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including pervasive developmental delay and GT dependent. On 01/30/2024 at 9:27 AM, in R11's room at the head of the bed on an intravenous (IV) pole, was a 30 milliliter (ml) open syringe with a tubing attachment. The 30 ml. syringe had no plunger and was attached to a plastic tubing to keep it above the level of the head of the resident. The syringe and the attached tubing contained residual tube feeding (TF) liquid. On 01/30/2024 at 9:39 AM, the registered nurse (RN) indicated the setup is for venting the resident's stomach after a TF regimen and the purpose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, the facility failed to ensure prophylactic antibiotics had a justification for usage for 1 of 14 sampled Residents (Resident 13). The deficient practice had the potential to prevent implementation of proper care and monitoring interventions based on the antibiotic justification. Findings include: Resident 13 (R13) R13 was admitted on [DATE] with diagnoses including acute lymphoblastic leukemia and autistic disorder. R13's medical record revealed a physician's order dated 06/10/2023 at 9:00 AM documented, Sulfamethoxazole-Trimethoprim (Bactrim) Oral Suspension 200-40 milligram (mg)/5 milliliter (ml), give 160 mg via gastrostomy (GT) every 12 hours every Saturday, Sunday for Prophylaxis Give 160 mg = 20 ml. Review of physician's progress notes from 06/2023 to current documented, continue with Bactrim 2x per day Saturday/Sunday, no end date per Hematology/Oncology. Review of nursing progress notes 06/2023 to current, lacked documentation as to why R13 was on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a surveillance device was in working condition to provide additional visual monitoring for the facility. The failure had the potential for decreased monitoring of the facility and lack of tools for reviewing incidences. Findings include: A tour of the facility revealed wall mounted surveillance cameras strategically located to monitor common areas of the lobby, dining/multipurpose area, and hallways. The cameras provided monitoring of the doors which serves as the entrance and exits for the facility. On 02/01/2024 at 3:36 PM, the Director of Nursing (DON) toured the information technology (IT) room where the camera monitor and recording devices were installed. The DON indicated the cameras aid the facility in terms of monitoring activities for both residents and staff in the common areas. The DON acknowledged the cameras were monitored by the use of a smartphone application. The DON indicated the access to the camera feeds is limited to the Administrator, the DON, and the Director of Maintenance. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.