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EVERGREEN TERRACE CARE CENTER LLC

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EVERGREEN TERRACE CARE CENTER LLC VS
Nursing Homes USA
General
City LAKEWOOD   0.2% Nursing Homes USA have LAKEWOOD
State attribute explanation CO   1.3% Nursing Homes USA have CO
Street 1625 SIMMS STREET  
Zip Code 80215  
Phone 3032388161  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
57 
108.94
Total Number of Residents
44 
91.25
Percent of Occupied Beds
77 %
83.65 %
Health Survey Date 12/7/2011  
Fire Survey Date 12/21/2011  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicaid  3.5% Nursing Homes USA have Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils Both  29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
75.2 
58.16
Total Enforcement Actions Count
75.2 
56.31
# of deficiencies 24  
Percent of long-stay residents experiencing one or more falls with major injury 75.2 % 
Staff Information
Number of Residents
44 
91.38
Number of RN Hours Per Resident Per Day
0.6 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.61 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.21 
1.59
Number of CNA Hours Per Resident Per Day
75.2 
5.49
Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/21/2012
date Of Correction: 07/20/2012 
Deficiency #2 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 12/07/2011
date Of Correction: 01/31/2012 
Deficiency #3 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/22/2011
date Of Correction: Not Available 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 10/06/2010
date Of Correction: 11/19/2010 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Maintain Comfortable And Safe Temperature Levels.
survey Date: 08/17/2010
date Of Correction: Not Available 
Deficiency #6 Scope: Many
level Of Harm: 2
deficiency: Make Sure That A Working Call System Is Available In Each Resident's Room Or Bathroom And Bathing Area.
survey Date: 04/15/2010
date Of Correction: 05/28/2010 
Deficiency #7 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 04/15/2010
date Of Correction: 05/28/2010 
Deficiency #8 Scope: Some
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 09/14/2009
date Of Correction: 10/27/2009 
Deficiency #9 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 05/07/2009
date Of Correction: 06/05/2009 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 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: 06/21/2012
date Of Correction: 07/20/2012 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: 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: 06/22/2011
date Of Correction: Not Available 
Deficiency #3 Scope: Few
level Of Harm: 3
deficiency: 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: 08/17/2010
date Of Correction: Not Available 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.
survey Date: 08/17/2010
date Of Correction: Not Available 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 06/21/2012
date Of Correction: 07/20/2012 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 08/17/2010
date Of Correction: Not Available 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 06/21/2012
date Of Correction: 07/20/2012 
Deficiency #2 Scope: Few
level Of Harm: 3
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 06/21/2012
date Of Correction: 07/20/2012 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 06/21/2012
date Of Correction: 07/20/2012 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 12/07/2011
date Of Correction: 01/31/2012 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 12/07/2011
date Of Correction: 01/31/2012 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 08/17/2010
date Of Correction: Not Available 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 09/14/2009
date Of Correction: 10/27/2009 
Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 05/07/2009
date Of Correction: 06/05/2009 
Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 06/21/2012
date Of Correction: 07/20/2012 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
59 %
25.09 %
Percent of long-stay residents who lose too much weight
9.8 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
75.2 %
15.63 %
Percent of long-stay residents with a urinary tract infection
75.2 %
13.46 %
Percent of long-stay residents who have depressive symptoms
4.9 %
28.38 %
Percent of long-stay residents who were physically restrained
7.3 %
43.68 %
Percent of long-stay residents experiencing one or more falls with major injury
2.4 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
58.5 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
9.3 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
12.5 %
9.22 %
Percent of long-stay residents who lose too much weight
8.8 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
50 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
75.2 %
10.65 %
Percent of long-stay residents with a urinary tract infection
6.4 %
9.58 %
Percent of long-stay residents who have depressive symptoms
3.1 %
19.86 %
Percent of long-stay residents who were physically restrained
7.8 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
3.1 %
10.73 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
37.5 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
31.7 %
74.75 %

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