| General |
| City |
| Wheat Ridge |
Canon City |
| State attribute explanation |
| Co |
Co |
| Street |
| 4800 Tabor Street |
1338 Phay Avenue |
| Zip Code |
| 80,033 |
81,212 |
| Phone |
| 3,034,214,161 |
7,192,852,540 |
|
Overall Star Rating |
| 3 |
4 |
|
Health Inspections Star Rating |
| 2 |
3 |
|
Nurse Staffing Star Rating |
| 4 |
4 |
|
Quality Measures Star Rating |
| 3 |
2 |
|
RN Only Star Rating |
| 4 |
3 |
|
Number of Certified Beds |
| 168 |
116 |
|
Total Number of Residents |
| 149 |
76 |
|
Percent of Occupied Beds |
| 89 % |
66 % |
| Health Survey Date |
| 4/12/2012 |
4/24/2012 |
| Fire Survey Date |
| 5/9/2012 |
5/14/2012 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| Non Profit - Church Related |
Non Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Both |
Resident |
| Continuing Care Retirement Community? |
| Yes |
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 |
| 6 |
10 |
|
| Staff Information |
| Number of Residents |
| 149 |
76 |
| Number of RN Hours Per Resident Per Day |
| 0.74 |
0.63 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.86 |
0.66 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.6 |
1.28 |
| Number of CNA Hours Per Resident Per Day |
| 0.03 |
0.07 |
| Number Therapy Hours Per Resident Per Day |
| 0.03 |
0.07 |
| Mistreatment Deficiencies |
| Deficiency #1 |
| Scope: Somelevel 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: 04/12/2012date Of Correction: 05/11/2012 |
|
| Resident Rights Deficiencies |
| Deficiency #1 |
| 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: 12/21/2011date Of Correction: 01/26/2012 |
Scope: Somelevel 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: 04/24/2012date Of Correction: 05/23/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Try To Resolve Each Resident's Complaints Quickly.survey Date: 12/21/2011date Of Correction: 01/26/2012 |
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: 04/24/2012date Of Correction: 05/23/2012 |
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 04/12/2012date Of Correction: 05/11/2012 |
Scope: Fewlevel 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: 04/24/2012date Of Correction: 05/23/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 04/21/2011date Of Correction: 06/08/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 04/24/2012date Of Correction: 05/23/2012 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 04/24/2012date Of Correction: 05/23/2012 |
| Deficiency #4 |
|
Scope: Somelevel Of Harm: 2deficiency: Provide Activities To Meet The Interests And Needs Of Each Resident.survey Date: 04/24/2012date Of Correction: 05/23/2012 |
| 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: 04/24/2012date Of Correction: 05/23/2012 |
| Administration Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.survey Date: 04/21/2011date Of Correction: 06/08/2011 |
|
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: At Least Once A Month, Have A Licensed Pharmacist Review Each Resident's Medication(s) And Report Any Irregularities To The Attending Doctor.survey Date: 04/24/2012date Of Correction: 05/23/2012 |
| Deficiency #2 |
|
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: 04/24/2012date Of Correction: 05/23/2012 |
| Nutrition and Dietary Deficiencies |
| Deficiency #1 |
|
Scope: Manylevel Of Harm: 2deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 04/24/2012date Of Correction: 05/23/2012 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 27.6 % |
17.7 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 2.8 % |
75.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 4.3 % |
9.5 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 1.3 % |
75.2 % |
| Percent of long-stay residents who lose too much weight |
| 5.2 % |
4.9 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 58.2 % |
50 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 5.3 % |
10.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 2.20 % |
9.8 % |
| Percent of long-stay residents who have depressive symptoms |
| 6.7 % |
17.7 % |
| Percent of long-stay residents who were physically restrained |
| 5.9 % |
1.6 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 11.4 % |
41 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 75.3 % |
77.5 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 84.4 % |
79.5 % |
| 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 |
| 5.2 % |
3.2 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 24.3 % |
16.2 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 1.50 % |
2.4 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 6.5 % |
9.7 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 5.6:1 |
3.1 % |
| Percent of long-stay residents who lose too much weight |
| 5.2 % |
6.6 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 63.8 % |
52.3 % |
| 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 |
| 2.20 % |
8.7 % |
| Percent of long-stay residents who have depressive symptoms |
| 8.3 % |
17.9 (64.2) |
| Percent of long-stay residents who were physically restrained |
| 6.6 % |
1.6 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 7.8 % |
3.8 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 11.4 % |
38.6 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 57.9 % |
79.2 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 86.8 % |
81 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 22.7 (72.9) |
15.1 % |