Colorow Care Center

In the surveyor’s words

From the most serious findings on record at Colorow Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Mar 26, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of three free of significant medication errors out of four sample residents. Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure and cognitive communication deficit. On 2/19/25 a nurse administered Resident #1 200 milligrams (mg) of pregabalin (nerve pain medicine) and 25 mg of metoprolol (blood pressure medication) in error. The resident began to experience nausea and was sent to the emergency room for monitoring. The resident experienced cardiac dysrhythmia (irregular heartbeat), hypotension (low blood pressure) and bradycardia (low heart rate). Findings include: I. […]

• Actual harm, isolatedF689Jul 24, 2023

  Based on observations, record review and interviews, the facility failed to ensure one (#1) out of five sample residents remained free from accident hazards. The facility failed to ensure a safe environment to prevent injury and death when transporting Resident #1. Resident #1 was involved in a motor vehicle accident on his way to an appointment on 6/29/23. The resident was taken to the hospital from the scene of the accident. He passed away on 6/29/23, shortly after the accident. The facility driving coordinator was the driver at the time of the accident. The facility driver rear ended another vehicle stopped in front of her at a traffic light when she took her eyes off the road. Findings include: I. […]

• Actual harm, isolatedF697Nov 23, 2021

  Based on record review and interviews, the facility failed to provide relief from acute pain during a condition change for one (#2) of three residents reviewed out of six sample residents. Resident #2 was experiencing a change of condition on [DATE] as evidenced by calling out, thrashing in bed, and guarding her left leg during assessment attempts. However, physician-ordered [MEDICATION(S)] medication to treat the resident's pain did not arrive and was not authorized for removal from the facility's emergency kit. Facility nursing staff did not follow up when the medication was not authorized in a timely manner, and the resident continued to experience pain assessed as high as severe 10 out of 10 pain. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service. Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24), chapter 2-301.12, retrieved on 5/5/26, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the… […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2024

  Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of two kitchenettes. Specifically, the facility failed to ensure: -Dented canned foods were not stored to be served to residents and food items were labeled with use-by dates; -Kitchen staff appropriately cleaned thermometers before temperatures were obtained from ready-to-eat foods; -Spare thermometers were kept in each refrigerator and freezer in case the digital thermometer went out and thermometers in the refrigerators and freezers were not broken; -Kitchen refrigerators were held at the appropriate temperature; and, -Cold foods were held at 41 degrees Fahrenheit (F) or below before serving residents. Findings include: I. […]