Neurorestorative Colorado

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Nutrition and Dietary Deficiencies

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Based on document review, observation, and interview, it was determined that fire-rated door assemblies were not maintained. The deficient practice could affect three out of three smoke compartments, 36 out of 36 residents, and an indeterminable number of staff and visitors. During observations and interviews, it was noted that the dining room egress door to the courtyard does not close or seal.During observations, interviews, and record review, it was noted t.. Based on document review, observation, and interview, it was determined that fire-resistant construction was not maintained. The deficient practice could affect one out of 3 smoke compartments, 12 out of 36 residents, and an indeterminable number of staff and visitors. During observation and interviews, it was noted that the medication room needs fire-stopping in the ceiling. NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide buil.. Based on document review, observation, and interview, it was determined that the facility failed to maintain the emergency power generator properly. The deficient practice could affect three out of three smoke compartments, 36 out of 36 residents, and an indeterminable number of staff and visitors. The facility was unable to furnish an annual fuel test report.NFPA 110, Section 8.3.8. A fuel quality test shall be performed at least annually using applicable AST.. Based on document review, observation, and interview, it was determined that the Fire Sprinkler system was not maintained. The deficient practice could affect three out of three smoke compartments, 36 out of 36 residents, and an indeterminable number of staff and visitors. Upon document review, the facility was missing two quarterly inspection reports. Upon document review, the facility was missing the 5-year internal inspection report.During obse.. Based on observation and interview, the facility failed to maintain the fire rating of hazardous areas. The deficient practice affected 1 out of 3 smoke compartments, 12 out of 36 residents, and an indeterminable number of staff and visitors. During the walkthrough with the administrator, it was observed that the mechanical room needs new fire-stopping systems in the ceiling and walls for piping and conduit. NFPA 101 8.3.3.1 Openings required to have a fi.. Based on record review and interviews, the facility failed to maintain proper records of the kitchen hood cleaning. The deficient practice affected all smoke compartments and all residents, staff, and visitors within the facility. The facility was unable to furnish a semi-annual kitchen hood cleaning report. NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed.. Based on the records review and the interview, the facility failed to inspect and test all emergency lighting. The deficient practice affected three out of three smoke compartments, and all residents, staff and visitors within the facility.The facility could not furnish a full-year documentation for 30-second monthly testing of the emergency exit lights. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three opt.. Based on the records review and the interview, the facility failed to inspect and test all emergency lighting. The deficient practice affected three out of three smoke compartments, and all residents, staff and visitors within the facility.The facility could not furnish documentation for the annual 90-minute emergency lighting testing and the full calendar year of monthly 30-second testing. 19.2.9 Emergency Lighting.19.2.9.1 Emergency lighting shall be provided.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on May 21st, 2025. for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies." This structure is a one (1) story wood frame structure having T..

A recertification survey with complaint #CO39750, Incident #39913 and Incident #39915 was completed on 4/28/25 to 5/1/25. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 4/28/25 to 5/1/25. No deficiencies were cited. 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 Re.. 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 referenceThe Inter.. 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 refrig.. 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 referenceAccording to the Centers for Dis.. 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 stand.. 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 referenceThe Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/6/25 read in pertinent part, "Commerc.. 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 referenceAccording to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or ..