RENO, NV - Federal inspectors found widespread infection control failures at Neurorestorative Nevada that put vulnerable residents at risk of serious illness and disease transmission.
Critical Infection Prevention Protocols Ignored
During a February 2025 inspection, surveyors discovered the facility failed to implement Enhanced Barrier Precautions (EBP) for 20 residents with indwelling medical devices, despite having policies and staff training on the requirements. These residents had feeding tubes, urinary catheters, and tracheostomies - medical devices that significantly increase infection risk.
Enhanced Barrier Precautions require healthcare workers to wear gowns and gloves during high-contact care activities with residents who have medical devices or chronic wounds. These precautions are designed to prevent dangerous organisms from transferring onto staff clothing and spreading to other residents throughout the facility.
The inspection revealed that staff consistently failed to wear required protective equipment when providing direct care to residents with medical devices. Inspectors observed multiple instances of nurses administering medications through feeding tubes and staff transferring residents without wearing the mandatory gowns.
Residents with Critical Medical Devices Left Unprotected
The affected residents included individuals with complex medical conditions requiring specialized care. Many had gastrostomy tubes for nutrition, indwelling urinary catheters for bladder management, and tracheostomies for breathing support. These medical devices create direct pathways into the body, making residents extremely vulnerable to life-threatening infections.
Gastrostomy tubes provide nutrition directly into the stomach but create an opening that can allow bacteria to enter the body. Improper handling during feeding or medication administration can introduce harmful organisms that cause severe abdominal infections or sepsis.
Indwelling urinary catheters drain urine from the bladder but frequently become colonized with bacteria. Without proper precautions during catheter care, these organisms can spread to cause urinary tract infections, kidney infections, or bloodstream infections that can be fatal in vulnerable populations.
Tracheostomies are surgical openings in the throat that bypass the mouth and nose - the body's natural barriers against infection. When healthcare workers don't use proper protective equipment during tracheostomy care, respiratory pathogens can easily spread between residents, causing pneumonia or other serious respiratory infections.
Respiratory Outbreak Investigation Failed
The facility also failed to properly investigate and control a significant increase in respiratory infections in its pediatric unit during December 2024. Four children developed respiratory infections compared to just one the previous month - a 400% increase that should have triggered immediate investigation and enhanced precautions.
Medical standards require facilities to investigate any unusual patterns of infection to identify potential sources and implement control measures. Respiratory infections in pediatric patients with complex medical conditions can rapidly progress to life-threatening complications including pneumonia, respiratory failure, or sepsis.
The facility's Infection Preventionist acknowledged the outbreak but stated no investigation was conducted because it occurred during "cold and flu season." This response fails to recognize that pediatric residents with tracheostomies and other medical devices face much higher risks from respiratory infections than healthy children.
Water Safety Testing Deficiencies
Inspectors found additional infection control failures in the facility's water management program. The facility was conducting legionella testing only twice yearly instead of the required quarterly testing outlined in their own policies.
Legionella bacteria thrive in water systems and can cause severe pneumonia, particularly dangerous for residents with compromised respiratory systems or tracheostomies. Regular testing ensures early detection and treatment of contaminated water supplies before residents are exposed.
The facility's water management program specifically required quarterly testing with results maintained in program documentation. However, maintenance staff could only provide test results from two dates in 2024, indicating systematic failure to follow their established safety protocols.
Medical Device Care Standards Ignored
Federal regulations and medical best practices require specific infection prevention measures for residents with medical devices. The Centers for Disease Control and Prevention established Enhanced Barrier Precautions specifically because multidrug-resistant organisms are common in long-term care facilities and contribute to substantial resident illness and death.
The facility's own policies, updated in January 2023, clearly outlined EBP requirements for residents with indwelling medical devices. Staff received training on these protocols during August 2024 meetings that included CDC guidance on Enhanced Barrier Precautions.
Despite having appropriate policies and training materials, nursing staff reported being unaware of EBP requirements. One nurse stated she had never heard of Enhanced Barrier Precautions and confirmed the facility was not using these protocols.
Industry Standards and Best Practices
Standard infection control protocols in healthcare facilities require layered approaches to prevent disease transmission. Enhanced Barrier Precautions represent an evidence-based strategy specifically developed for long-term care settings where vulnerable residents face elevated infection risks.
Medical device management requires strict adherence to manufacturer guidelines and infection prevention protocols. Each type of device has specific care requirements designed to minimize infection risk while maintaining device function.
Outbreak investigation procedures mandate immediate response to unusual infection patterns. Facilities must identify potential sources, implement enhanced precautions, and monitor for additional cases to prevent widespread transmission.
Regulatory Response and Facility Operations
The inspection resulted in citations for infection prevention and control program failures affecting multiple residents. The facility serves individuals with complex neurological conditions requiring specialized medical care and rehabilitation services.
Neurorestorative Nevada operates as a skilled nursing facility providing long-term care for residents with traumatic brain injuries, spinal cord injuries, and other neurological conditions. Many residents require ventilator support, enteral nutrition, and extensive medical management.
The Director of Nursing and Regional Infection Preventionist acknowledged the facility had not implemented Enhanced Barrier Precautions for any residents despite identifying 20 individuals who met the criteria. They stated the facility was "still working on how to implement EBP" to comply with state and federal recommendations.
Health Impact and Risk Assessment
The documented violations create significant health risks for all facility residents and staff. Inadequate infection prevention allows dangerous organisms to spread throughout the facility, potentially causing outbreaks of antibiotic-resistant infections.
Residents with medical devices face particularly high risks because these devices provide direct pathways for bacteria to enter the body. Without proper protective equipment, healthcare workers can unknowingly transfer harmful organisms between residents during routine care activities.
Respiratory infections in pediatric patients with tracheostomies can rapidly deteriorate into life-threatening conditions requiring emergency medical intervention. The facility's failure to investigate and implement control measures left vulnerable children at continued risk of serious complications.
The inspection findings highlight systematic failures in infection prevention that could result in preventable illnesses, prolonged hospitalizations, or death among the facility's medically complex resident population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Neurorestorative Nevada from 2025-02-21 including all violations, facility responses, and corrective action plans.
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