Neurorestorative Colorado

In the surveyor’s words

From the most serious findings on record at Neurorestorative Colorado, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 31, 2023

  Based on observations, record review and interviews, the facility failed to ensure the resident environment remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for one (#15) of one resident reviewed for accidents and hazards out of 17 sample residents. Specifically, the facility failed to: -Ensure Resident #15 did not receive first/second degree burns to both thighs during the use of electrical stimulation in a physical therapy session; -Ensure Resident #15 had a physician order in place for use of neuromuscular electrical stimulation (NMES); and -Ensure the therapy care plan documented therapy use of NMES for Resident #15. Findings include: I. […]

• Actual harm, isolatedF600Nov 1, 2021

  Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from neglect. The facility failed to ensure Resident #1 was not neglected by staff on [DATE] by providing the care and services the resident required to maintain the highest practicable well-being. Resident #1 was left outside on [DATE] unchecked on the front patio of the facility in full sun, for at least three hours from approximately 11:00 a.m. until he was found by staff at approximately 2:00 p.m. When the resident was located on the patio, he was unresponsive and had a body temperature of 109 degrees fahrenheit. The resident was transported to a local hospital emergency room where he was diagnosed with [CONDITION(S)] secondary to hyperthermia and dehydration. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen and nourishment refrigerator/freezer. Specifically, the facility failed to ensure time and temperature control food was labeled, dated and disposed of timely. Findings include: I. Professional reference The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/6/25 read in pertinent part, Commercially processed food: open and hold cold, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the… […]

• No harm, potential for more than minimal, widespreadF801Aug 31, 2023

  Based on record review and interviews, the facility failed to employ a director of food and nutrition services with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 19 census residents. Specifically, the facility failed to ensure the business office manager (BOM) who was in charge of the kitchen services, had sufficient qualifications for this position. Findings include: I. Facility policy and procedures The Dietary and Food Kitchen Supervisor policy, effective date of 2/12/19, was provided by the nursing home administrator (NHA) on 8/31/23 at 12:42 p.m. The policy revealed the kitchen supervisor was responsible for providing the day to day direction to kitchen staff, and overseeing food preparation. […]

• No harm, potential for more than minimal, patternF700May 1, 2025

  Based on observations, record review and interviews, the facility failed to ensure accurate assessments, informed risks, and ongoing monitoring was in place for three (#1, #13 and #6) of six residents with bed rails out of 20 sample residents. Specifically, the facility failed to: -Ensure risks of bed rails were explained to Resident #1 or the resident' s representatives prior to the initiation of the bed rails; -Ensure bed rail assessments were accurately completed for Resident #1, Resident #6 and Resident #13; -Ensure consent was obtained for the use of a bed rail from Resident #1; and, -Ensure ongoing monitoring of bed rails in use was completed for Resident #1, Resident #6 and Resident #13. Findings include: I. Resident #1 A. […]