| General |
| City |
| Englewood |
Commerce City |
| State attribute explanation |
| Co |
Co |
| Street |
| 3575 South Washington Street |
5230 East 66th Way |
| Zip Code |
| 80,110 |
80,022 |
| Phone |
| 3,037,892,265 |
3,032,891,848 |
|
Overall Star Rating |
| 4 |
2 |
|
Health Inspections Star Rating |
| 3 |
1 |
|
Nurse Staffing Star Rating |
| 4 |
4 |
|
Quality Measures Star Rating |
| 4 |
4 |
|
RN Only Star Rating |
| 4 |
4 |
|
Number of Certified Beds |
| 86 |
105 |
|
Total Number of Residents |
| 60 |
86 |
|
Percent of Occupied Beds |
| 70 % |
82 % |
| Health Survey Date |
| 10/12/2011 |
5/15/2012 |
| Fire Survey Date |
| 11/8/2011 |
6/7/2012 |
| 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 |
| Resident |
Resident |
| 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 |
1 |
| # of deficiencies |
| 24 |
23 |
|
| Staff Information |
| Number of Residents |
| 60 |
86 |
| Number of RN Hours Per Resident Per Day |
| 0.91 |
0.82 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.74 |
0.84 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.65 |
1.65 |
| Number of CNA Hours Per Resident Per Day |
| 0.2 |
0.07 |
| Number Therapy Hours Per Resident Per Day |
| 0.2 |
0.07 |
| 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: 06/28/2012date Of Correction: 07/31/2012 |
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: 12/29/2011date Of Correction: 01/27/2012 |
| 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: 10/12/2011date Of Correction: 11/16/2011 |
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: 09/14/2011date Of Correction: Not Available |
| Deficiency #3 |
| Scope: Somelevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 10/12/2011date Of Correction: 11/16/2011 |
Scope: Somelevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 09/14/2011date Of Correction: Not Available |
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 01/20/2011date Of Correction: 02/28/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| Deficiency #5 |
| 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: 11/18/2009date Of Correction: 12/18/2009 |
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: 09/15/2010date Of Correction: 12/09/2010 |
| Deficiency #6 |
|
Scope: Somelevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| 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: 06/28/2012date Of Correction: 07/31/2012 |
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: 09/15/2010date Of Correction: 10/20/2010 |
| Deficiency #2 |
| 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: 11/18/2009date Of Correction: 12/18/2009 |
|
| Resident Rights Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Listen To The Resident Or Family Groups Or Act On Their Complaints Or Suggestions.survey Date: 06/28/2012date Of Correction: 07/31/2012 |
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: 12/29/2011date Of Correction: 01/27/2012 |
| Deficiency #2 |
| 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: 08/16/2011date Of Correction: 09/19/2011 |
Scope: Somelevel Of Harm: 2deficiency: Listen To The Resident Or Family Groups Or Act On Their Complaints Or Suggestions.survey Date: 09/14/2011date Of Correction: Not Available |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Help And Prepare Each Resident For A Safe And Easy Discharge And Transfer From The Nursing Home.survey Date: 11/18/2009date Of Correction: 12/18/2009 |
Scope: Fewlevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 06/28/2012date Of Correction: 07/31/2012 |
Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 12/29/2011date Of Correction: 01/27/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.survey Date: 06/28/2012date Of Correction: 07/31/2012 |
Scope: Fewlevel Of Harm: 2deficiency: Give Each Resident Enough Fluids To Keep Them Healthy And Prevent Dehydration.survey Date: 09/14/2011date Of Correction: Not Available |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Activities To Meet The Interests And Needs Of Each Resident.survey Date: 06/28/2012date Of Correction: 07/31/2012 |
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: 09/14/2011date Of Correction: Not Available |
| Deficiency #4 |
| 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: 01/25/2012date Of Correction: 02/29/2012 |
Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| Deficiency #5 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 01/25/2012date Of Correction: 02/29/2012 |
Scope: Somelevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| Deficiency #6 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure That Residents With Reduced Range Of Motion Get Proper Treatment And Services To Increase Range Of Motion.survey Date: 10/12/2011date Of Correction: 11/16/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| Deficiency #7 |
| Scope: Somelevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 10/12/2011date Of Correction: 11/16/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Give Or Get Specialized Rehabilitative Services Per The Patient's Assessment Or Plan Of Care.survey Date: 08/10/2010date Of Correction: 09/03/2010 |
| Deficiency #8 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.survey Date: 10/12/2011date Of Correction: 11/16/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 08/10/2010date Of Correction: 09/03/2010 |
| Deficiency #9 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 08/16/2011date Of Correction: 09/19/2011 |
|
| Deficiency #10 |
| Scope: Fewlevel Of Harm: 2deficiency: Give Each Resident Enough Fluids To Keep Them Healthy And Prevent Dehydration.survey Date: 01/20/2011date Of Correction: 02/28/2011 |
|
| Deficiency #11 |
| Scope: Fewlevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 11/18/2009date Of Correction: 12/18/2009 |
|
| Resident Assessment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.survey Date: 10/12/2011date Of Correction: 11/16/2011 |
Scope: Fewlevel 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: 09/15/2010date Of Correction: 10/20/2010 |
| 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: 12/29/2011date Of Correction: 01/27/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 09/15/2010date Of Correction: 10/20/2010 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.survey Date: 10/12/2011date Of Correction: 11/16/2011 |
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: 09/15/2010date Of Correction: 10/20/2010 |
| Deficiency #2 |
| Scope: Somelevel Of Harm: 2deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.survey Date: 07/14/2009date Of Correction: 08/17/2009 |
|
| Nutrition and Dietary Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 09/14/2011date Of Correction: Not Available |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 11.6:1 |
34.5 % |
| 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 |
| 14.5 % |
14.7:1 |
| Percent of long-stay high-risk residents with pressure ulcers |
|
8.3 % |
| Percent of long-stay residents who lose too much weight |
| 75.2 % |
4.1 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
|
40 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 75.2 % |
6.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 4.5 % |
2.7 % |
| Percent of long-stay residents who have depressive symptoms |
| 2.3 % |
75.2 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 32.8 % |
|
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 50.7 % |
48.8 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 46.3 % |
45.8 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 |
1 |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 4.5 % |
1.3 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 12.7 % |
32.8 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 0.9 % |
75.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 12.5 % |
15.2 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 2.5 % |
8.1 / 8.8 |
| Percent of long-stay residents who lose too much weight |
| 4.4 % |
4.6 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 23.7 (74.7) |
35.4 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 3.1 % |
6.9 % |
| Percent of long-stay residents with a urinary tract infection |
| 6.6 % |
4.6 % |
| Percent of long-stay residents who have depressive symptoms |
| 3.1 % |
0.8 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 5.1 % |
2.1 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 27.3 % |
18.7 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 47 % |
51.7 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 49.8 % |
51.4 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 18 % |
75.2 % |