Neurorestorative Nevada

F-F602

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 295103 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295103 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caremeridian Llc, Dba Neurorestorative 3980 Lake Placid Drive Ste 2 Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31739 potential for actual harm Based on clinical record review, interview and document review, the facility failed to ensure an investigation Residents Affected - Few 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.

Findings include:

Resident #1

Resident #1 was admitted to the facility on [DATE REDACTED], with diagnoses including spastic diplegic cerebral palsy, diabetes insipidus, and contractures of the right and left knees.

Resident #1's Care Plan revised 07/03/2024, documented the resident had a fall with injury on 07/01/2024, and to follow the facility's fall protocol.

A Final FRI report submitted by the facility; documented Resident #1 had a fall in the resident's room while receiving care on 07/01/2024. The resident was assessed, and an X-ray was ordered. The FRI report lacked documentation where the fracture was located on the resident or what additional treatment the resident had received.

On 02/20/2025 at 10:32 AM, the Regional Support Director of Nursing verbalized having been unable to locate the facility's investigation report for Resident #1's fall in July 2024, and the only investigation information and documentation the facility had were the documents submitted with the FRI to the State Agency.

The facility policy titled, Abuse-Dependent Adult/Child, revised 01/06/2016, documented the facility would provide a written report of the results of an investigation and the appropriate action taken to the State Agency or others, as required by law.

FRI #NV00071611

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 295103 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295103 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caremeridian Llc, Dba Neurorestorative 3980 Lake Placid Drive Ste 2 Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 46301 potential for actual harm Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant Residents Affected - Few (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.

Findings include:

Employee #6

Employee #6 was hired on 09/20/2023, as a CNA.

Employee #6's personnel record lacked documented evidence an annual performance review had been conducted by the employee's anniversary date of 09/20/2024.

On 02/20/2025 at 1:30 PM, the Office Manager confirmed Employee #6 did not have an annual performance evaluation for 2024 and Employee #6's annual performance evaluation for 2024 was completed late and the annual performance evaluation had not been completed for 2025. The Office Manager verbalized all CNAs were required to have an evaluation every year by the hire date and they were to be completed by the Director of Nursing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 295103

F-F609.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 295103 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295103 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caremeridian Llc, Dba Neurorestorative 3980 Lake Placid Drive Ste 2 Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49557

Residents Affected - Few Based on interview, clinical record review, and document review the facility failed to ensure an allegation of neglect for 1 of 12 sampled residents (Resident #17) and an allegation of misappropriation of personal property for 1 of 2 residents sampled for closed records (Resident #25) were reported to the State Agency (SA) within the required timeframe. This deficient practice could result in an untimely investigation of the allegations.

Findings include:

Resident #17

Resident #17 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, disorders of diaphragm, dependence on respiratory (ventilator) status, and tracheostomy status.

A Facility Reported Incident (FRI) was submitted to the SA on 11/05/2024, documenting an allegation of neglect by a Respiratory Therapist (RT) when the RT did not provide physician ordered care to Resident #17.

The FRI documented the alleged incident occurred around 10/27/2024.

Documentation of the facility's investigation of the allegation included physician orders, respiratory administration records, a photo of a ventilator log, statements from staff, emails written by the Respiratory Manager (RM), a corrective action plan, and a termination notice.

An email sent from the RM to the RM's supervisor (identified by the RM as the Respiratory Regional Director)

on 10/30/2024 at 3:27 PM, documented the RM was aware of the following concerns reported by Resident #17's family member:

-The RT of concern was not providing required care to Resident #17 as ordered by the physician.

-The RT demonstrated a lack of concern for multiple residents to which the RT was assigned to care for.

-The lack of care by the RT may have contributed to Resident #17's rehospitalization in October 2024.

On 02/20/2025 at 5:32 PM, the Administrator, who was also the facility's Abuse Coordinator, verbalized all allegations of abuse and neglect were required to be reported to SA immediately or within 24 hours, depending on the severity. The Administrator confirmed failure of facility staff to provide physician ordered care was considered neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 295103 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295103 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caremeridian Llc, Dba Neurorestorative 3980 Lake Placid Drive Ste 2 Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 The Administrator verbalized the Administrator was familiar with an allegation the RT of concern did not provide physician ordered care to Resident #17. The Administrator explained the concern was initially Level of Harm - Minimal harm or reported to the facility's Marketer (a sales employee who saw residents in the hospital) on 10/30/2024, and potential for actual harm the Administrator was notified of the allegation on 11/05/2024. The Administrator confirmed the Marketer was employed by the facility and the allegation should have been reported to the Administrator and the SA prior Residents Affected - Few to 11/05/2024.

The facility policy titled Abuse - Dependent Adult/Child, revised 10/02/2024, documented neglect included failure to provide medical care for physical and mental health needs and failure to provide goods and services needed to avoid physical harm, mental anguish, or emotional distress. Abuse of a resident included neglect and deprivation by a caregiver of goods or services necessary to avoid physical harm or mental suffering. The facility was to report all alleged violations and all substantiated incidents to the SA and to all other agencies as required, in a timely manner. Any person who worked for or had a contractual agreement with the facility was a mandated reporter. Mandatory reporters were not permitted to pass on the reporting obligation to another employee. Staff would immediately (including after hours) report all incidents or suspected incidents of resident abuse, mistreatment, and neglect to the Administrator/DON and the correct reporting agency. When an alleged or suspected case of mistreatment, neglect, or abuse was reported, the Administrator/DON would notify the SA immediately but not later than 24 hours of the alleged incident. Suspected child abuse was required to be reported immediately.

FRI #NV00072622

50210

Resident #25

Resident #25 was admitted to the facility on [DATE REDACTED], and discharged on [DATE REDACTED], 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. The previous ADON calculated the resident's cash and confirmed the missing money.

A witness statement from a Registered Nurse (RN), dated 02/03/2025, documented on 12/04/2024, Resident #25's cash and valuables previously stored in the RN's medication cart were secured in the Administrator's office at the insistence of the Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 295103 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295103 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caremeridian Llc, Dba Neurorestorative 3980 Lake Placid Drive Ste 2 Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 On 02/20/2025 at 11:27 AM, the Administrator verbalized the Administrator removed resident possessions from the medication carts and placed them in a lock box in the Administrator's office. The Administrator Level of Harm - Minimal harm or recalled on 12/18/2024, the Recreational Therapist spoke with the Administrator about needing cash to pay potential for actual harm vendors at the facility. The Administrator had a petty cash check for 220 dollars and 90 dollars in cash. However, the vendors needed to be paid immediately and there was not time to cash the check. The Residents Affected - Few Administrator verbalized 100 dollars in cash was removed from Resident #25's property kept in the lock box

in the Administrator's office and was used to pay the vendors.

The Administrator verbalized the Administrator did not intervene or report to the SA when the incident occurred because the Administrator was preparing to go on vacation. The Administrator explained the event would be considered misappropriation because the facility took money from the resident without the resident's consent.

On 02/20/2025 at 2:05 PM, the Administrator verbalized the Administrator was the facility's Abuse Coordinator and was a mandated reporter. The Administrator explained misappropriation must be reported to

the SA within two hours and the investigation completed immediately.

The facility policy titled, Funds, Resident Trust Funds, Surety Bonds and Valuables, revised 09/26/2018, documented misuse of funds or property belonging to a resident may be considered misappropriation or financial exploitation and would be reported. Examples of misuse included theft of money, commingling of funds, and transfer of resident funds to a facility account

FRI #NV00073128.

Complaint #NV00073200.

Cross reference with