NeuroRestorative

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all residents were free from physical restraints. Specifically, 1 resident was restrained during oral care. Resident Identifier: 1. Findings include: The surveyor reviewed the facility's grievance log. The grievance log revealed that on March 3, 2025, the facility received an incident report from the school that Resident 1 attended, regarding a possible abuse event that happened on February 28, 2025 with Respiratory Therapist (RT) 1 and Resident 1. The following summary was documented in the log: Resident 1 was visibly upset during oral care that RT 1 was performing. Resident 1 was attempting to cover their face during these cares. Registered Nurse (RN) 1 offered assistance, and RT 1 declined assistance. RT 1 instead, put Resident 1's hands between RT 1's knees in order to continue oral care. The abuse coordinator for the facility was contacted once the incident report was received. After the incident, RT 1 was removed from…

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 interview and record review, the provider did not ensure that all alleged violations were reported. Specifically, allegations of abuse were not reported to the State Survey Agency (SSA) within the 2 hour timeframe. Resident Identifier: 1 Findings include: The surveyor reviewed the facility's grievance log. The grievance log revealed that on March 3, 2025, the facility received an incident report from the school that Resident 1 attended, regarding a possible abuse event that happened on February 28, 2025 with Respiratory Therapist (RT) 1 and Resident 1. The following summary was documented in the log: Resident 1 was visibly upset during oral care that RT 1 was performing. Resident 1 was attempting to cover their face during these cares. Registered Nurse (RN) 1 offered assistance, and RT 1 declined assistance. RT 1 instead, put Resident 1's hands between RT 1's knees in order to continue oral care. The abuse coordinator for the facility was contacted once the incident report was received. The surveyor completed a review of the SSA's facility reported incident system and could…

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 and interview it was determined, 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. Specifically, for 3 out of 20 sampled residents, staff members were observed to not clean the Hoyer lift after each resident use. Resident identifiers: 1, 23 and 55. Findings include: On 11/6/24 at 10:30 AM, an observation was made of Certified Nursing Assistant (CNA) 1. CNA 1 was observed to bring the Hoyer lift out of the room of resident 55 and place it in the hallway. CNA 1 did not clean the Hoyer lift. Resident 55 was observed to be on enhanced barrier precautions. On 11/6/24 at 10:46 AM, an observation was made of the Hoyer [NAME] being taken into resident 23's room by CNA 2. Resident 23 was observed to be in contact isolation along with enhanced barrier precautions. CNA 2 was observed to have a gown, mask and…

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 and record review it was determined for 1 of 20 sample residents the facility did not ensure that each resident received adequate supervision and services to prevent accidents. Specifically, a resident was transferred on a utility cart causing a fall resulting in bruising and abrasions. Resident identifier: 42 Resident 42 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included infantile spinal muscular atrophy, type I Werding-[NAME], dysphagia, other lack of expected normal physiological development in childhood, abnormalities of gait and mobility, tracheostomy status, mandibular hypoplasia, and chromosomal abnormality. Review of records was completed on 11/4/24 through 11/7/24. On 10/16/24 at 10:59 PM, a Daily Skilled Charting note for Resident 42 revealed the following. At approximately 2000 [8:00 PM]; CNA [certified nurse assistant] witnessed the patient fall and hit her forehead and nose on the carpet in the hall. (Skin issues listed above) CNA, RT…

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 and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 11 sampled residents, a resident with a fracture of unknown source and a resident with an allegation of neglect was not submitted to the SSA within two hours of becoming aware of the incidents. Resident identifiers: 2 and 6. Findings included: 1. Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included spastic quadriplegic cerebral palsy; lennox-gastaut syndrome, intractable, with status epilepticus; chronic respiratory failure with hypoxia, dependence on respirator status; tracheostomy status; pleural effusion; ileus; contracture of muscle, multiple sites; neuromuscular…

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 and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 26 sampled residents, the end of the feeding tubing was not capped when not attached to a resident and the end of the tubing was not cleaned after it touched different surfaces and was then inserted into the residents feeding appliance. Resident identifiers: 33, 35, 42, 50, and 56. Findings included: On 4/17/23 at 9:50 AM, an observation was made of resident 50's feeding tubing which was draped over the top of the feeding pole. The feeding was observed to not be infusing and there was not a cap on the end of the feeding tubing line. On 4/17/23 at 10:00 AM, an observation as made of resident 35's feeding tubing which was draped over the top of the feeding pole. The feeding was observed to not be infusing and there was not a cap on the end of the feeding tubing line. The end of the line was…

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 and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 out of 26 sampled residents, a resident who had falls did not have a care plan that was updated after each fall. Resident identifier: 20. Findings included: Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anoxic brain injury, gastroesophageal disorder, anemia, epilepsy, dementia, chronic respiratory failure, dependence on a ventilator, chronic communication deficit, and aphasia. On 4/18/22, resident 20's medical record was reviewed. A Quarterly Fall Risk assessment dated [DATE], revealed resident 20 was a moderate fall risk. A care plan for risks for falls was…

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 and record review, it was determined, the services provided or arranged by the facility did not meet professional standards of quality. Specifically, for 1 out of 26 sampled residents, discharge orders from the hospital were not correctly transcribed and the double check failed to notice the incorrect medication order, resulting in one resident receiving two doses of the wrong antibiotic. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, ventilator associated pneumonia, acute and chronic respiratory failure with hypoxia, and urinary tract infection. Resident 53's Medical Record was reviewed on 4/18/23. On 2/27/23, Resident 53 was readmitted to the facility with discharge orders from the hospital. An antibiotic was included in the medication discharge order which was Ceftazidime 2 grams. On 2/27/23, a Facility readmission Order Summary Report was created by Assistant…

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 and record review, the facility did not ensure that the pharmacist reported irregularities of a resident's drug regimen were reviewed by the facility physician and the reports acted upon. Specifically, for 1 out of 26 sampled residents, the facility did not provide the recommendations to the facility physician for review and the recommendation was not implemented. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] with diagnoses that included [NAME] Nile Virus infection with encephalitis, asthma, severe protein-calorie malnutrition, respiratory failure with hypoxia, anoxic brain damage, dementia with behavioral disturbance, metabolic encephalopathy, obstructive sleep apnea, anxiety disorder, mood disorder, attention deficit hyperactivity disorder, low back pain, and dysphasia. Resident 23's medical record was reviewed. On 10/28/22, the facility Family Nurse Practitioner ordered lidocaine patches for resident 23. The order documented Apply to back…

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 and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 26 sampled residents, a resident's hypertensive medication used to treat high blood pressure was not monitored according to the physician's ordered parameters. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, sequelae of cerebral infarction, chronic respiratory failure, dependence on respirator, chronic diastolic heart failure, epilepsy, dysphagia, hypertension, sepsis, cerebral infarction, and tracheostomy status. Resident…

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 and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 26 sampled residents, a resident with an Insulin sliding scale physician's order to check the resident's blood glucose (BG) every (Q) two hours until the BG was less than 180, did not have the BG checked per the physician's order. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, sequelae of cerebral infarction, chronic respiratory failure, dependence on respirator, chronic diastolic heart failure, epilepsy, dysphagia, hypertension, sepsis, cerebral infarction, and tracheostomy status. Resident 18's medical record was reviewed on 4/20/23. A physician's order dated 3/1/23, documented HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML [milliliter] (Insulin Lispro (1 Unit Dial)) Inject as per sliding scale: if 0 - 69 = 0 call md [Medical…

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 and record review, the facility did not ensure that the drug regimen of 4 of 22 sample residents was reviewed at least once a month by a licensed pharmacist. In addition, one resident had a pharmacist recommendation that was not reviewed by the physician. Resident identifiers: 11, 30, 31, and 46. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, aphasia, unspecified intracranial injury with loss of consciousness of unspecified duration, spastic hemiplegia, and dysphagia. Resident 11's medical record was reviewed on 9/13/21. The pharmacy consultant reports were reviewed. No record could be found to indicate that resident 11's medications were reviewed by the pharmacy consultant for the months of June, July and August 2021. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses that included unspecified intracranial injury. Resident 31's medical record was reviewed on 9/13/21. The pharmacy consultant…

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 and interview, it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility staff did not wear appropriate Personal Protective Equipment when interacting with residents on isolation precautions. Resident identifiers: 15, 30 and 37. Findings include: 1. On 9/13/21 at approximately 9:00 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that resident rooms 25 through 36 were on transmission based precautions due to a recent potential exposure to COVID-19. On 9/13/21 at 3:00 PM, an observation was made of Physical Therapist (PT) 1. PT 1 was observed to be in room [ROOM NUMBER], with a resident. PT 1 observed to be standing next to the resident's bed, and was reaching down to pick up items off of a chair next to the bed, as she spoke with the resident. PT 1 was observed to not be wearing a gown or gloves. PT 1 was observed to leave…

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.