Neurorestorative

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF658Mar 10, 2023

  Based on observation, interview, record review, and document review, the facility failed to ensure the nursing staff did not sign off on the medication administration record before administering the medication in PODS 1, 2, and 3. Failure to accurately document the medication administration could potentially result in medication errors, falsified medication records, altered therapeutic benefits, medication underdosing or overdosing, and adverse reactions. Findings include: Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including gastrostomy status, gastroparesis (delayed stomach emptying) and gastro-esophageal reflux disease with esophagitis. On 03/09/2023 at 7:53 AM, during medication pass observation, a Registered Nurse 2 (RN2) in POD 2 prepared R11's medications. […]

• No harm, potential for more than minimal, patternF880Mar 12, 2021

  Based on observation, interview, record review and document review, the facility failed to ensure appropriate COVID-19 infection control measures were implemented as evidenced by: 1) not informing staff members timely of the COVID-19 outbreak, 2) not seeking the direction of the required Personal Personal Protective equipment (PPE) of the Medical Director regarding COVID-19 facility policies, 3) not wearing PPE during the administration of aerosol-generating procedures (AGPs) for 5 of 5 [MEDICAL CONDITION] sampled residents (Residents #1, #2, #3, #4, #5). […]

• No harm, potential for more than minimal, isolatedF600Aug 6, 2026

  Based on observation, interview, record review and document review the facility failed to ensure a vulnerable pediatric resident was free from neglect when for 1 of 3 sampled residents (Resident 1). The deficient practice had the potential to result in access to electrical outlets, sharp objects, oxygen tanks, tubing, cords and other environmental hazards including placing objects in the mouth which could cause choking, entanglement or serious injury.Findings include:Resident 1 (R1) was admitted on [DATE], and readmitted on [DATE], with diagnoses including delayed milestone in childhood and child in welfare custody.The facility report dated 06/24/2026, documented child neglect involving R1, a one-year and five-month-old with delayed developmental milestones. […]

• No harm, potential for more than minimal, isolatedF657Apr 17, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure a care plan for enteral feeding was reviewed and updated after a resident was hospitalized for aspiration pneumonia for 1 of 22 sampled residents (Resident 7). The deficient practice placed the residents at risk for repeat aspiration episodes and other tube feeding-related complications. Findings include: Resident 7 (R7) was admitted on [DATE] and readmitted [DATE], with diagnoses including malignant neoplasm of the brain and gastrostomy status. A respiratory flow chart summary dated 01/07/2026, documented R7 had been vomiting since 4:30 AM and was placed up in wheelchair at 6:30 AM. R7 was looked pale and Oxygen saturation did not have good reading. […]

• No harm, potential for more than minimal, isolatedF689Apr 17, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure a resident's crib environment was free from accidental hazards when cords were observed hanging into a crib for one unsampled resident (Resident 35). The deficient practice placed the resident at risk for entanglement.Findings include:Resident 35 (R35) was admitted on [DATE], with diagnoses including extreme immaturity of a newborn at 26 weeks, cortical blindness and anoxic brain injury. The annual minimum data set (MDS) dated [DATE], revealed R35 had no impairment on upper and lower extremity, was nonverbal and hard of hearing. On 04/16/2026 at 7:45 AM, R35 was asleep inside crib. On the left side of the crib hung two cords - one for the light switch and one for the call system. […]