RENO, NV - Federal inspectors found that Neurorestorative Nevada failed to maintain proper investigation documentation for a resident who experienced a fall resulting in fracture and missed required annual performance evaluations for nursing staff during a February 2025 inspection.
Critical Documentation Failures in Serious Injury Investigation
The most significant violation occurred when facility administrators were unable to provide investigators with the complete internal investigation report for a serious fall incident. A resident with spastic diplegic cerebral palsy, diabetes insipidus, and knee contractures fell in their room while receiving care on July 1, 2024, sustaining a fracture that required X-ray imaging.
When state surveyors requested the facility's investigation documentation in February 2025, the Regional Support Director of Nursing admitted they could not locate the internal investigation report. The facility had only submitted the basic Facility Reported Incident (FRI) form to the state agency, which contained minimal information about the incident.
The submitted FRI report documented that the resident fell during care delivery and was subsequently assessed with X-rays ordered, but failed to specify the location of the fracture or detail what additional medical treatment the resident received following the injury. This incomplete documentation represented a significant gap in the facility's incident response protocols.
Federal regulations require nursing homes to conduct thorough investigations of all serious incidents and maintain comprehensive documentation of their findings and corrective actions. The facility's own policy, titled "Abuse-Dependent Adult/Child," specifically states that written investigation reports must be provided to state agencies as required by law.
Medical Implications of Inadequate Incident Investigation
Falls represent one of the most serious safety risks in nursing homes, particularly for residents with mobility limitations and neurological conditions like cerebral palsy. When a fall results in fracture, proper investigation becomes critical for several medical and safety reasons.
Comprehensive fall investigations serve multiple essential purposes in healthcare settings. They identify environmental hazards that could cause future incidents, evaluate whether proper fall prevention protocols were followed, assess if the resident's care plan needs modification, and determine if staff require additional training or support.
For residents with cerebral palsy and existing contractures, falls can be particularly dangerous due to compromised mobility, altered balance, and increased fracture risk from potential bone density issues. The spastic nature of diplegic cerebral palsy affects muscle control in the lower extremities, making these individuals more vulnerable to falls and subsequent injuries.
When facilities fail to conduct thorough investigations, they miss opportunities to implement preventive measures that could protect not only the injured resident but others with similar risk factors. The medical consequences of inadequate investigation extend beyond the immediate incident, potentially allowing conditions that contributed to the fall to persist and endanger other vulnerable residents.
Proper fracture management in residents with cerebral palsy requires careful monitoring, as healing may be complicated by muscle spasticity, contractures, and potential mobility restrictions. Without complete investigation documentation, medical staff may lack crucial information about the mechanism of injury, which can impact treatment decisions and rehabilitation planning.
Systematic Staffing Oversight Deficiencies
The inspection also revealed failures in staff performance monitoring systems. A Certified Nursing Assistant who had been employed since September 2023 did not receive their required annual performance evaluation by their anniversary date in September 2024. When inspectors arrived in February 2025, this evaluation had still not been completed.
The facility's Office Manager confirmed during the survey that the CNA's 2024 annual performance evaluation was completed late, and the 2025 evaluation remained outstanding. The manager acknowledged that all CNAs are required to receive annual evaluations by their hire date anniversary, with these assessments to be conducted by the Director of Nursing.
Performance evaluations serve critical functions in healthcare settings, particularly for direct care staff who interact with vulnerable residents daily. These assessments identify knowledge gaps that may require additional training, ensure staff maintain competency in essential skills, provide opportunities for professional development feedback, and document staff performance for quality assurance purposes.
In nursing home environments, where residents often have complex medical needs requiring specialized care approaches, regular performance monitoring becomes essential for maintaining care quality standards. CNAs provide the majority of hands-on resident care, making their competency assessment particularly important for resident safety and wellbeing.
The failure to conduct timely evaluations potentially allows performance issues to go unaddressed, which could impact the quality of care provided to residents. Regular evaluations also ensure that staff receive necessary continuing education and remain current with best practices in long-term care.
Regulatory Standards and Industry Best Practices
Federal nursing home regulations mandate that facilities maintain comprehensive incident investigation procedures and conduct regular staff performance assessments. These requirements exist to protect resident safety and ensure quality care delivery.
The Centers for Medicare & Medicaid Services requires nursing homes to investigate all incidents involving potential abuse, neglect, or injury to residents. Complete investigation documentation must include detailed incident descriptions, witness statements, environmental assessments, corrective actions taken, and preventive measures implemented.
Industry best practices for fall investigation include immediate medical assessment, environmental hazard evaluation, review of the resident's care plan and fall risk factors, staff interview and training assessment, and development of enhanced prevention strategies. Facilities should also conduct root cause analysis to identify systemic issues that may have contributed to the incident.
For staff performance management, federal regulations require nursing homes to ensure nursing assistants receive adequate supervision and training. This includes regular performance evaluations that assess competency, identify training needs, and document professional development progress.
Professional healthcare organizations recommend annual performance reviews include evaluation of clinical skills, communication abilities, adherence to policies and procedures, resident interaction quality, and identification of continuing education needs. These assessments should be documented and used to develop individualized professional development plans.
Additional Issues Identified
The inspection documented violations in two key areas affecting resident safety and care quality. The facility's inability to locate investigation documentation for a serious fall incident violated federal requirements for proper incident response and reporting. Additionally, the failure to conduct timely annual performance evaluations for nursing staff violated regulations requiring adequate supervision and competency assessment of direct care providers.
Both violations were classified as having minimal harm or potential for actual harm, but inspectors noted they could potentially affect all facility residents by compromising incident investigation processes and staff oversight systems.
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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