Caremeridian LLC, Dba Neurorestorative

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure 1) a resident and/or the resident representative, and the Ombudsman were notified of the reason for transfer in writing when a resident was transferred to an acute care hospital for inpatient care for 1 of 2 residents reviewed for closed records (Resident #30) and 3 of 3 sampled residents reviewed for hospitalizations (Resident #26, #2, #5) and 2) a resident and/or the residents representative were provided notification of the facility's bed hold policy upon transfer to an acute care hospital for 1 of 3 sampled residents reviewed for hospitalizations (Resident #5). [...]

Inspectors wroteBased on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure 1) the infection prevention program included a process to ensure staff were screened for eligibility to receive a Covid-19 (COVID) vaccine, education was provided regarding the COVID vaccine to be administered, consent was obtained, the vaccine was administered or declined, and documentation of the vaccination or declination was retained, and 2) an Infection Preventionist (IP) worked at the facility from 09/17/2025 through 03/31/2026.

Inspectors wroteBased on interview and document review the facility failed to ensure 1) an Infection Preventionist (IP) with the required specialized training worked at the facility from 09/17/2025 through 03/31/2026, and 2) the IP had a process in place to ensure staff were offered COVID-19 vaccines. This deficient practice had the potential to increase the risk of infection transmission within the facility.

Inspectors wroteBased on interview, and document review the facility failed to 1) ensure facility staff were screened annually for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided, and the vaccine was offered and either administered or declined, and 2) failed to develop and implement policies and procedures related to COVID immunizations. This deficient practice had the potential to affect compliance with vaccination requirements and increase the risk of disease transmission.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Director of Nursing (DON) served at the facility on a full-time basis for 2 of 15 months reviewed for sufficient and competent nurse staffing. This deficient practice had the potential to compromise nursing care received by all residents in the facility.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure 3 of 3 residents participating in the resident council were free from verbal abuse and neglect by Certified Nursing Assistant (CNA1). This deficient practice had the potential to cause psychological harm and expose residents to emotional distress, indignity, and risk of infection due to inadequate hygiene, privacy, and responsiveness.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the environment was free from accident hazards related to the use of side rails for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in serious injury, including entrapment, by placing the resident at risk for preventable harm.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to maintain accurate controlled drug records (CDR) for 1 of 12 sampled residents (Resident #5) in 1 of 2 reviewed narcotic logs books. This deficient practice had the potential to result in medication errors, inaccurate documentation of controlled substances, and increased risk of harm to residents due to improper handling of medications.

Inspectors wroteBased on record review, interview and document review, the facility failed to ensure behavior and side effect monitoring for psychotropic medication was completed for 1 of 12 sampled residents (Resident #18), and failed to ensure an order for pregabalin (a nerve pain medication) was not entered twice in the resident's set of active medication orders and Medication Administration Record (MAR) for 1 of 12 sampled residents (Resident #9). This deficient practice had the potential to result in medication errors and cause physical harm to the resident.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure resident food items placed in refrigeration were appropriately labeled and dated. These deficient processes have the potential to result in consumption of expired food, and increased risk of illness for residents. On 05/04/2026 at 09:25 AM, during pediatric section satellite kitchen inspection, resident food, including a take-out container with accoutrements and quart of milk with no visible placement date or use by date were observed on the top shelf of the refrigerator. Although no food containers were marked, a placard placed in front of the food items provided a resident name and room number. An uncovered partially consumed ice cream type product was contained in a cup in the freezer. There was no visible resident name, placement date, or use by date information on the cup.

Inspectors wroteBased on interview and document review, the facility failed to ensure Administration: (1) verified the Infection Preventionist (IP) possessed the required training and competency to effectively educate, track, and monitor staff COVID 19 (COVID) vaccinations, and (2) ensured staff were screened for eligibility, provided education on the COVID vaccine, and offered the vaccine with documentation of acceptance or declination. This deficient practice placed the resident population at increased risk of exposure to and infection from COVID.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met.

Inspectors wroteBased on observation, interview, and document review, the Quality Assurance and Process Improvement (QAPI) committee failed to identify the QAPI committee did not include the required members.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) Isolation Precautions were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 12 sampled residents (Resident #15), and 2) the Infection Prevention and Control Plan (IPCP) included all of the required elements. These deficient practices had the potential to increase the risk of spreading infectious organisms throughout the facility.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely for 2 of 19 sampled employees (Employee #5 and #11). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure behavioral health care training was completed timely for 3 of 19 sampled employees (Employee #5, #11, and #16). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure 1 of 10 sampled residents (Resident #4) was treated with respect and dignity when the resident's belongings were not inventoried and were removed from the resident's room without notification. This deficient practice had the potential to result in psychosocial harm to the resident and misappropriation of resident property.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency (SA) for 1 of 10 sampled residents (Resident #6). This deficient practice had the potential to prevent timely investigation of abuse allegations and leave residents vulnerable to abuse.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure an allegation of abuse was investigated for 1 of 10 sampled residents (Resident #6). This deficient practice had the potential to leave residents vulnerable to abuse.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to document the specific resident needs the facility could not meet and attempts to meet the resident's needs when the facility declined to readmit a resident following an acute care hospitalization for 1 of 10 sampled residents (Resident #2). This deficient practice had the potential for residents to be discharged from the facility without a safe discharge plan.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to provide written notice of the facility's bed-hold policy to a resident and the resident's representative upon transfer to an acute care hospital for 1 of 10 sampled residents (Resident #2). This deficient practice had the potential to result in psychosocial harm to residents due to not being able to return to the resident's previous room.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure clinical records were complete and accurate for 1 of 10 sampled residents (Resident #7). This deficient practice had the potential to result in duplicate administration of treatments/medications to residents and for residents' response to care provided and refusals of care to not be documented and available for review as necessary.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was permitted to return to the facility following a visit to the hospital for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to result in an unsafe and unnecessary resident discharge, placing the resident at risk for physical and emotional harm

Inspectors wroteBased on interview and document review, the Administrator failed to ensure the Facility Assessment (FA) included all portions of the facility's resident population and any ethnic, cultural or religious factors with the potential to affect the care provided by the facility. This deficient practice had the potential to deprive residents of necessary care and services to meet each resident's individual needs and preferences.

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure corrective action was implemented to address identified problems related to the lack of Enhanced Barrier Precautions (EBP) for residents with a chronic wound or indwelling medical device. This deficient practice had the potential to result in the exposure of all residents, staff and visitors to harmful infectious agents.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure 1) Enhanced Barrier Precautions (EBP) were implemented for 20 of 20 residents with an indwelling medical device (Resident #2, #14, #8, #23, #17, #10, #15, #6, #9, #228, #5, #7, #1, #20, #4, #176, #19, #3, #227, and #12) according to the facility's policy, training provided at a staff meeting, and Centers for Disease Control (CDC) guidance, 2) an increase in respiratory infections in the pediatric unit was investigated and control measures were implemented for 4 of 9 residents with infections in December 2024 (Resident #7, #17, #15, and #3) and 3) quarterly legionella testing was completed according to the facility's water management program. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure resident grievances were documented, investigated and a determination and/or resolution was provided to the resident(s). This deficient practice had the potential to result in a resident having an unresolved grievance.

Inspectors wroteBased on observation, interview, and document review the facility failed to remove expired medications from the active supply in 2 of 2 medication storage rooms and 2 of 3 medication carts reviewed for medication storage. This deficient practice had the potential for expired medications to be administered to residents.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure initial and annual elder abuse prevention training was completed timely for 6 of 18 sampled employees (Employees #2, #3, #6, #7, #10, and #11). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on clinical record review and interview, the facility failed to provide the Center for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN), and Form 10123, Notice of Medicare Non-Coverage (NOMNC) for 1 of 2 residents discharged from a Medicare covered Part A stay with benefit days remaining within the previous six months (Resident #26). This deficent practice had the potential to negatively impact the resident(s) ability to make informed decisions about their care.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure a comfortable, homelike environment when a resident had reported the exit door for employees in the 200 Hall had been closing loudly resulting in disruption in the resident's sleep for 1 of 11 residents in the 200 Hall (Resident #2). This deficient practice had the potential to affect the resident's sleep patterns by exposing the resident to unnecessary noise disturbances, potentially leading to a less comfortable living environment.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure 1 of 12 sampled residents (Resident #17) was kept safe from neglect by a Respiratory Therapist (RT). This deficient practice had the potential for the resident to experience emotional and physical harm.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident was protected from misappropriation of personal property for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to result in resident's limited access to financial resources as well as mental and emotional harm.

Inspectors wroteResident #25 Resident #25 was admitted to the facility on [DATE], and discharged on 01/22/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. An FRI was submitted to the SA on 01/07/2025, documenting an allegation of misappropriation of resident property involving the facility Administrator and the Recreational Therapist when resident property was commingled with facility petty cash. The FRI documented the alleged incident occurred around 12/20/2024, and the interim Administrator was notified of the allegations on 01/07/2025. A grievance form filled by the previous Assistant Director of Nursing (ADON) dated 12/26/2024, documented Resident #25 signed out the resident's wallet from the lock box in the Administrator's office, and noticed 100 dollars in cash was missing from the resident's property. [...]

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure an investigation of a Facility Reported Incident (FRI) related to a resident fall was available for State Agency to review for 1 of 4 residents investigated for FRI (Resident #1). This deficient practice had the potential to affect all residents, resulting in incomplete investigations of potential incidents of abuse and neglect.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident not meeting the circumstances of discharge requirements was permitted to remain in the facility for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to result in an unnecessary and unsafe discharge.

Inspectors wroteBased Based on interview, clinical record review, and document review, the facility failed to ensure a resident received written notification of discharge prior to discharge for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to prevent the resident from being informed of the date of, reason for, and right to appeal the discharge.

Inspectors wroteBased on interview and clinical record review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #19). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions and services relative to their current health management needs.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a discharge assessment and plan was completed prior to discharge, and medications were provided to a discharged resident for 1 of 2 residents sampled for closed records (Resident #25). This deficient practice had the potential to prevent the resident from having a safe discharge and could result in inadequate post-discharge care coordination.

Inspectors wroteBased on personnel record review, document review, and interview, the facility failed to ensure direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for 2 of 12 sampled direct care employees (Employee #14 and #16). This deficient practice could result in a negative outcome for a resident requiring CPR while awaiting the arrival of emergency medical personnel.

Inspectors wroteBased on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #6). This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of insevice education/training.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure an as needed (PRN) psychotherapeutic medication was prescribed to a resident with a diagnosed indication for use, was limited to 14 days, was monitored for side effects, and had behavior monitoring for 1 of 12 sampled residents (Resident #19). This deficient practice had the potential to result in an unmanaged medication regimen, missed signs of worsening condition, and compromised resident safety.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure physical therapy (PT) frequency of treatment was provided per the physician's order for 1 of 12 sampled residents (Resident #3). This deficient practice had the potential to prevent residents from attaining or maintaining the residents' highest practicable level of strength, balance, and endurance.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure 1) residents with psychotherapeutic medications had a documented pre-restraining assessment per facility policy for 5 of 5 residents sampled for unnecessary medications (Residents #9, #17, #2, #13, and #19) and 2) a consent had been obtained for a psychotherapeutic medication per the facility's policy for 1 of 5 residents sampled for unnecessary medications (Resident #9). This deficient practice had the potential to result in the accidental use of psychotherapeutic medications as chemical restraints and residents receiving psychotherapeutic medications prior to being informed of the risks and benefits of the medication.

Inspectors wroteBased on interview, and document review the facility failed to ensure education regarding the facility's Antimicrobial Stewardship Program (ASP)/antibiotic use was provided to staff and facility staff documented an evaluation to determine if residents met or did not meet McGeer criteria, according to the facility's program/policy, prior to initiation of antibiotic therapy. This deficient practice had the potential to affect all residents in the facility and placed residents at risk of developing antibiotic-resistant infections. Staff training On 02/19/2025 at 2:45 PM, a Registered Nurse (RN) verbalized the RN had worked for the facility for approximately one year. The RN denied the RN had received any training related to the facility's antimicrobial/antibiotic stewardship program. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide twelve hours of in-service training as a result of performance evaluations for 2 of 2 sampled Certified Nursing Assistants (CNA) who have been with the facility for more than one year. This deficient practice had the potential to place all residents at risk of receiving care from staff without the required knowledge and competency to perform their duties.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was discarded per facility policy, properly labeled, food was properly stored, hand hygiene was performed during a trayline observation, and a high temperature dishwasher reached 180 degrees Fahrenheit (F) on the rinse cycle.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the dietary staff followed the menu or requested approval from the Registered Dietician to change the menu, prior to preparing and plating the meal, and posted the substitution for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident or resident representative gave informed consent prior to the administration of a psychotropic medication for 2 of 12 sampled residents (Resident #17 and #77).

Inspectors wroteBased on interview and document review, the facility failed to ensure the Resident Council was able to meet as a group.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a care plan for resident discharge and a careplan for medication with side effect monitoring was developed for 4 of 12 sampled residents (Resident #24, #76, #77, and #78).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Comprehensive Care Plan was updated to include the care and interventions for wounds, infections, and falls for 3 of 12 sampled residents (Resident #4, #18, and #77).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure assessment for entraptment were completed, alternatives were attempted, and informed consent was obtained prior to installation of side rails for 1 of 12 sampled residents (Resident #76).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure expired medical supplies were removed from 1 of 3 medication carts.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dietary staff were trained to understand the type of sanitization performed by the dishwashing machine (dishwasher) and to accurately and effectively monitor the temperature of the rinse cycle on the high temperature dishwasher.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the outside receptacles were sealed (lid closed) and free of debris on the surrounding pavement.

Inspectors wroteBased on interview and document review the facility failed to ensure quarterly payroll-based staffing (PBJ) requirements were submitted to Center for Medicare and Medicaid Services (CMS). The failure to submit PBJ data prevented CMS to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website.