| General |
| City |
| Colorado Springs |
Montrose |
| State attribute explanation |
| Co |
Co |
| Street |
| 924 West Kiowa |
1043 Ridge Street |
| Zip Code |
| 80,905 |
81,401 |
| Phone |
| 7,196,365,221 |
9,702,499,683 |
|
Overall Star Rating |
| 4 |
4 |
|
Health Inspections Star Rating |
| 3 |
3 |
|
Nurse Staffing Star Rating |
| 4 |
2 |
|
Quality Measures Star Rating |
| 2 |
5 |
|
RN Only Star Rating |
| 4 |
4 |
|
Number of Certified Beds |
| 83 |
104 |
|
Total Number of Residents |
| 54 |
70 |
|
Percent of Occupied Beds |
| 65 % |
67 % |
| Health Survey Date |
| 7/12/2011 |
8/5/2011 |
| Fire Survey Date |
| 7/29/2011 |
9/1/2011 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| For Profit - Limited Liability Company |
For Profit - Limited Liability Company |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| None |
Both |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| Yes |
Yes |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 75.2 |
75.2 |
| Total Enforcement Actions Count |
| 75.2 |
75.2 |
| # of deficiencies |
| 7 |
7 |
|
| Staff Information |
| Number of Residents |
| 54 |
70 |
| Number of RN Hours Per Resident Per Day |
| 0.66 |
0.86 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.94 |
0.55 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.6 |
1.41 |
| Number of CNA Hours Per Resident Per Day |
| 0.09 |
0.08 |
| Number Therapy Hours Per Resident Per Day |
| 0.09 |
0.08 |
| Environmental Deficiencies |
| Deficiency #1 |
| 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: 04/21/2009date Of Correction: 05/20/2009 |
|
| Mistreatment Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 3deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 03/31/2011date Of Correction: 05/05/2011 |
| Resident Rights Deficiencies |
| Deficiency #1 |
| 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: 02/09/2011date Of Correction: 03/22/2011 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Give The Resident's Representative The Ability To Exercise The Resident's Rights.survey Date: 02/09/2011date Of Correction: 03/22/2011 |
|
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 03/07/2012date Of Correction: 04/06/2012 |
Scope: Fewlevel Of Harm: 3deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 03/31/2011date Of Correction: 05/05/2011 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 02/09/2011date Of Correction: 03/22/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 11/10/2009date Of Correction: 12/04/2009 |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 3deficiency: Give Proper Treatment To Residents With Feeding Tubes To Prevent Problems (such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-pharyngeal Ulcers) And Help Restore Eating Skills, If Possible.survey Date: 04/21/2009date Of Correction: 05/20/2009 |
|
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 04/21/2009date Of Correction: 05/20/2009 |
|
| Resident Assessment Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.survey Date: 11/10/2009date Of Correction: 12/04/2009 |
| Administration Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 03/31/2011date Of Correction: 05/05/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 11/10/2009date Of Correction: 12/04/2009 |
| 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: 03/31/2011date Of Correction: 05/05/2011 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 35.7 % |
14.5 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 1.9 % |
75.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 24 % |
14.5 % |
| Percent of long-stay high-risk residents with pressure ulcers |
|
75.2 % |
| Percent of long-stay residents who lose too much weight |
| 5.8 % |
1.6 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 50 % |
55.1 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 6.7 % |
6.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 3.8 % |
3.2 % |
| Percent of long-stay residents who have depressive symptoms |
| 21.2:1 |
75.2 % |
| Percent of long-stay residents who were physically restrained |
| 5.8 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 30.8 % |
22.5 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 75.4 % |
79.6 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 75.8 % |
100 % |
| 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 |
| 1.9 % |
1.6 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 37.1 % |
16.7 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 1.6 % |
75.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 21.5 % |
12.5 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 6.8 % |
1.1 % |
| Percent of long-stay residents who lose too much weight |
| 5.1 % |
1.2 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 40.3 % |
60.3 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 6 % |
5.9 % |
| Percent of long-stay residents with a urinary tract infection |
| 1.3 % |
4.3 % |
| Percent of long-stay residents who have depressive symptoms |
| 19.6 % |
0.6 % |
| Percent of long-stay residents who were physically restrained |
| 5.7 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 1.3 % |
3 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 34.6 % |
19.9 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 66.5 % |
42.9 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 68.9 % |
100 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 22.3 % |
12.6:1 |