Neurorestorative

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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]; [...]

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 26 sampled residents, a resident developed a pressure injury after their alternating pressure mattress deflated. In addition, there was a delay in treatment. Resident identifier: 18.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.