NeuroRestorative

In the surveyor’s words

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

• Immediate jeopardy, patternF760Aug 19, 2026

  Based on observation, interview and record review, it was determined that for 5 of 29 sampled residents, the facility did not ensure that residents were free from significant medication errors. Specifically, one resident was administered insulin outside of a physician's ordered parameters and had to receive glucagon to raise his blood glucose to normal levels, a second resident was administered oxycodone 10mg (milligrams) instead of his prescribed clonazepam 0.5mg for seizures, and a third resident missed two consecutive doses of insulin, then received long acting insulin instead of short acting insulin as prescribed. Resident identifiers: 1, 25, 32, 34 and 52. The findings for three residents were determined to have resulted in immediate jeopardy. […]

• Immediate jeopardy, isolatedF695Sep 23, 2022

  Based on interview and record review, it was determined that for 1 of 4 sampled residents, the facility failed to provide emergent respiratory care, in accordance with professional standards of practice, for a resident with a decannulated [CONDITION(S)] ([CONDITION(S)]). Specifically, a dependent and vulnerable resident whose [CONDITION(S)] had decannulated was not assessed appropriately and was not immediately provided emergency respiratory care. The resident was transferred to a pediatric hospital where she passed away 5 days later. The deficient practice identified was found to have occurred at immediate jeopardy (IJ) level. […]

• Actual harm, isolatedF689Apr 30, 2025

  Based on observation, interview, and record review, the provider failed to ensure that all residents had appropriate supervision to prevent accidents. Specifically, one resident was given reheated coffee that spilled and caused scalding burns, which required hospitalization in the burn unit. Additionally, another resident fell out of bed and sustained a head laceration that required sutures when a CNA raised the resident's bed and momentarily left the resident unattended, and a third resident fell during a staff-assisted transfer due to the resident's wheelchair not being locked by staff before initiating the transfer. Resident Identifiers: 3, 4, and 5. Findings include: 1. On April 30, 2025, the surveyor interviewed Resident 5. […]

• Actual harm, isolatedF760Nov 7, 2024

  Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident that was not diabetic was administered Insulin instead of Heparin, was hypoglycemic, and was admitted to the hospital. Resident identifier: 111. Findings included: Resident 111 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included, but were not limited to, anoxic brain damage, neuromuscular dysfunction of bladder, post traumatic stress disorder, major depressive disorder, anorexia, cardiac arrest, chronic respiratory failure, urinary tract infection, Methicillin-resistant Staphylococcus aureus (MRSA), pressure ulcer of sacral region unstageable, hypotension, dysphagia,… […]

• Actual harm, isolatedF600Feb 20, 2024

  Based on interview and record review the facility failed to prevent abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 1 out of 11 sampled residents, a staff member who preformed a blood draw left a tourniquet on a resident's leg for multiple hours, resulting in a pressure injury (PI). Resident identifier: 6 Findings included: Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, displaced fracture of third cervical vertebra, displaced fracture of second cervical vertebra, dissection of vertebral artery, intentional self-harm by other firearm discharge, dependence on respirator status, acute and chronic respiratory failure, narcolepsy, major depressive disorder, and unspecified… […]