Neurorestorative Colorado

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 food shall be consumed on the premises, sold, or discarded, the day the original container is opened in the food establishment shall be counted as day one and the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included surgical aftercare on the skin, pressure ulcers, traumatic subdural hemorrhage (brain injury where blood accumulates between the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for each resident. Specifically, the facility failed to: -Provide a balanced menu for residents; -Ensure Resident #5 received a variety of pureed dessert options; -Ensure international dysphagia diet standardization initiative (IDDSI) standards were utilized for production of IDDSI modified texture diet orders; and, -Ensure Resident #18 received a minced and moist level five texture diet instead of a pureed diet. Findings include: I. Professional reference The International Dysphagia Diet Standardization Initiative (IDDSI) minced and moist level five patient handout (2019) and retrieved 5/8/25, read in pertinent part, Meat is served finely minced or chopped to 4 millimeter (mm) lump size served in a thick, smooth, non-pouring sauce or gravy. Vegetables are cooked, finely mashed or use a blender to finely chop it into to 4 mm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to implement their policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to: -Implement the facility policy for food brought by visitors and ensure food that was kept in resident's refrigerators had safe and sanitary storage; and, -Ensure the residents personal refrigerator temperatures were monitored correctly for appropriate temperatures. Findings include: I. Professional reference The Colorado Retail Food Regulations, (3/16/24) were retrieved on 5/6/25. It read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. (3-501.16) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17) The Food and Drug Administration (FDA) food code (3/27/23) were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to ensure residents on a pureed diet out of 20 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed pureed texture diets were served food that was prepared according to their diet order as indicated on their meal tray cards. Findings include: I. Professional reference The International Dysphagia Diet Standardization Initiative (IDDSI) Pureed Audit Tool (September 2020) retrieved 5/6/25 read in pertinent part, Critical appearance of pureed food: no lumps, food slides smoothly and easily between fingers. A puree needs to be able to be put in the mouth and swallowed whole. No chewing and no bolus (a soft mass of chewed food) formation skills should be needed to eat this. II. Meal observation During a continuous observation on 4/30/25, beginning at 11:55 a.m. and ending at 12:18 p.m., the following was observed during the meal preparation and service in the kitchen: The posted menu was lazy stuff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one of two units. Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care for Resident #1. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 5/5/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal vaccinations for one (#5) of five residents out of 20 sample residents. Specifically, the facility failed to provide the pneumococcal vaccination to Resident #5. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 5/6/25, from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. II. Resident #5 A. Resident status Resident #5, over age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included a history of intracranial injury and subdural…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The supervisor was also responsible for the distribution of meals to residents served; maintained the cleanliness of the kitchen; ensured all quality assurance tasks were completed; and ensured compliance with local, state/federal regulations as well as company policies. The minimum qualifications for this position included a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#9) of one resident reviewed for hospice services out of 17 sample residents. Specifically the facility failed to: -Ensure a contract was signed between the facility and the hospice agency; -Ensure a hospice care plan was initiated for Resident #9 determining who was responsible for resident care; and -Ensure there was a medical diagnosis for hospice services. Findings include: I. Facility policy and procedure The Hospice protocol, dated 3/4/2020, received from the nursing home administrator (NHA) on 8/30/23 at 9:43 a.m., revealed in pertinent part, To ensure that all residents receiving hospice services have a plan of care that has a comprehensive plan of care that specifies delineation of services for the facility and the hospice company and to ensure all hospice members are trained on the facility policies and procedures. Procedure: an order for hospice services should be entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene was done by food service staff; and, -The cutting boards were free from deep scratches and stains making them an uncleanable surface. Findings include: I. Improper hand hygiene A. Professional references Colorado Retail Food Establishment Rules and Regulations, effective 1/1/19, section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment utensils, and unwrapped single, service and single use articles and: food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food clean equipment and utensils, and unwrapped single, service and single service articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days for two (#22 and #26) of five residents reviewed for unnecessary medications out of 17 sample residents. Specifically, the facility failed to discontinue a PRN psychoactive medication after 14 days without a physician's rationale for Resident #22, and Resident #26. Findings include I. Resident #22 A. Resident status Resident #22, age [AGE], was admitted on [DATE]. According to the February 2020 CPO, diagnoses included diffuse traumatic brain injury, traumatic subdural hemorrhage with loss of consciousness, memory deficit, and cognitive social or emotional deficit. According to the 1/24/2020 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The MDS documented the resident ' s cognitive skills for daily decision making was moderately impaired. The resident had mild depression with the resident scoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#10) of one resident reviewed for hospice services out of 17 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure Resident #10, had a written plan of care which included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. Findings include: I. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 CPO, diagnoses included pressure ulcer of sacral region,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.