| General |
| City |
| Colorado Springs |
Colorado Springs |
| State attribute explanation |
| Co |
Co |
| Street |
| 1795 Monterey Road |
110 West Van Buren Street |
| Zip Code |
| 80,910 |
80,907 |
| Phone |
| 7,194,717,850 |
7,194,758,686 |
|
Overall Star Rating |
| 2 |
2 |
|
Health Inspections Star Rating |
| 1 |
1 |
|
Nurse Staffing Star Rating |
| 4 |
4 |
|
Quality Measures Star Rating |
| 4 |
3 |
|
RN Only Star Rating |
| 5 |
4 |
|
Number of Certified Beds |
| 112 |
91 |
|
Total Number of Residents |
| 78 |
71 |
|
Percent of Occupied Beds |
| 70 % |
78 % |
| Health Survey Date |
| 4/28/2011 |
3/16/2011 |
| Fire Survey Date |
| 5/11/2011 |
4/13/2011 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| For Profit - Corporation |
For Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Both |
Both |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| Yes |
No |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 2 |
75.2 |
| Total Enforcement Actions Count |
| 3 |
75.2 |
| # of deficiencies |
| 8 |
27 |
|
| Staff Information |
| Number of Residents |
| 78 |
71 |
| Number of RN Hours Per Resident Per Day |
| 0.94 |
0.85 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.7 |
1 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.64 |
1.84 |
| Number of CNA Hours Per Resident Per Day |
| 0.09 |
0.06 |
| Number Therapy Hours Per Resident Per Day |
| 0.09 |
0.06 |
| Environmental Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Fewlevel Of Harm: 3deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 01/27/2012date Of Correction: 03/02/2012 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Maintain Comfortable And Safe Temperature Levels.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #4 |
|
Scope: Somelevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 08/05/2010date Of Correction: Not Available |
| Mistreatment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Fewlevel Of Harm: 2deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.survey Date: 01/27/2012date Of Correction: 03/02/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Fewlevel Of Harm: 2deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.survey Date: 08/05/2010date Of Correction: Not Available |
| Resident Rights Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Each Resident Has The Right To Have A Choice Over Activities, Their Schedules And Health Care According To His Or Her Interests, Assessment, And Plan Of Care.survey Date: 01/27/2012date Of Correction: 03/02/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Tell The Resident Or The Resident's Representative In Writing How Long The Nursing Home Will Hold The Resident's Bed.survey Date: 12/13/2010date Of Correction: 01/19/2011 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #4 |
|
Scope: Fewlevel Of Harm: 2deficiency: Help And Prepare Each Resident For A Safe And Easy Discharge And Transfer From The Nursing Home.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #5 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Enough Notice Before Discharging Or Transferring A Resident.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #6 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Written Records When A Resident Is Transferred Or Discharged.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #7 |
|
Scope: Fewlevel Of Harm: 2deficiency: Try To Resolve Each Resident's Complaints Quickly.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #8 |
|
Scope: Fewlevel Of Harm: 2deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.survey Date: 08/05/2010date Of Correction: Not Available |
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Somelevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 03/16/2011date Of Correction: 04/19/2011 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure That Each Resident Gets A Nutritional And Well Balanced Diet, Unless It Is Not Possible To Do So.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Somelevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 03/16/2011date Of Correction: 04/19/2011 |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 3deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Manylevel Of Harm: 2deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.survey Date: 05/03/2012date Of Correction: 06/13/2012 |
Scope: Fewlevel Of Harm: 2deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #5 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #6 |
|
Scope: Fewlevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #7 |
|
Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #8 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #9 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 08/05/2010date Of Correction: Not Available |
| Deficiency #10 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.survey Date: 08/05/2010date Of Correction: Not Available |
| Resident Assessment Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.survey Date: 01/27/2012date Of Correction: 03/02/2012 |
| Administration Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 03/16/2011date Of Correction: 04/19/2011 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.survey Date: 08/05/2010date Of Correction: Not Available |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 35.8 % |
|
| Percent of long-stay residents whose need for help with daily activities has increased |
| 75.2 % |
7 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 16.2 % |
|
| Percent of long-stay high-risk residents with pressure ulcers |
| 10.5 % |
|
| Percent of long-stay residents who lose too much weight |
| 5.4 % |
6.3 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 42.9 % |
|
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 6 % |
|
| Percent of long-stay residents with a urinary tract infection |
| 5.4 % |
6.1 % |
| Percent of long-stay residents who have depressive symptoms |
| 6.8 % |
11.4 % |
| Percent of long-stay residents who were physically restrained |
| 1.4 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 32 % |
23.1 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 76 % |
83.7 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 41.5 % |
86 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 1.4 % |
75.2 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 34.3 % |
21.2:1 |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 75.2 % |
5.7 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 15.8 % |
13.1:1 |
| Percent of long-stay high-risk residents with pressure ulcers |
| 5.7 % |
5.9 % |
| Percent of long-stay residents who lose too much weight |
| 4 % |
3.7 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 47.8 % |
44.2 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 5.8 % |
8 % |
| Percent of long-stay residents with a urinary tract infection |
| 4.9 % |
9.5 % |
| Percent of long-stay residents who have depressive symptoms |
| 10.7:1 |
6.9 % |
| Percent of long-stay residents who were physically restrained |
| 0.9 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 1.3 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 30.9 % |
21.7 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 63.2 % |
86.2 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 40.8 % |
88 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 19 % |
19 % |