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BETHANY REHABILITATION CENTER - LAKEWOOD, CO

 



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Address
5301 WEST FIRST AVENUE
LAKEWOOD, CO, 80226
Phone (make sure to verify first before calling): (303) 238-8333

Number of Certified Beds: 170
Total Number of Residents: 160
Percent of Occupied Beds: 94%
Sprinkler Status: Fully Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: For profit - Corporation
Located Within a Hospital?: No
Multi Nursing Home Ownership?: Yes
Resident and Family Councils: Both
Continuing Care Retirement Community?: No
Quality Indicator Survey?: Yes
Special Focus Facility?: No
Type: Skilled Nursing Facilities

Overall Star Rating: 2 Stars
Health Inspections Star Rating: 1 Star
Nurse Staffing Star Rating: 5 Stars
Quality Measures Star Rating: 3 Stars
RN Only Star Rating: 5 Stars

Employment Full-Time Equivalent

Administrative Staff - Full Time: 2.86
Certified Nurse Aides - Full Time: 45.86
Certified Nurse Aides - Part Time: 1.63
Dietitians - Under Contract: 0.09
Food Service Personnel - Full Time: 12.30
Food Service Personnel - Part Time: 1.90
Housekeeping Personnel - Full Time: 14.51
Licensed Practical/ Vocational Nurses - Full Time: 23.79
Licensed Practical/ Vocational Nurses - Part Time: 1.80
Medical Directors - Under Contract: 0.10
Mental Health Services Personnel - Under Contract: 1.37
Nurses With Administrative Duties - Full Time: 3.00
Registered Nurses - Full Time: 6.73
Rn Director Of Nursing - Full Time: 1.14
Activities Professionals - Full Time: 1.14
Dentists - Under Contract: 0.09
Pharmacists - Under Contract: 0.17
Physical Therapists - Part Time: 0.90
Podiatrists - Under Contract: 0.09
Physician Extenders - Under Contract: 1.71
Sppech Pathologists - Full Time: 1.07
Registered Nurses - Part Time: 1.49
Social Workers - Under Contract: 0.11
Occupational Therapists - Full Time: 2.20
Physical Therapists - Full Time: 2.46
Physical Therapy Aide - Full Time: 2.19

Provided Services

  • Activities Services Are Provided Onsite To Residents
  • Administration And Storage Of Blood Services Are Provided Offsite To Residents
  • Clinical Laboratory Services Are Provided Onsite To Residents
  • Dental Services Are Provided Onsite To Residents
  • Diagnostic Xray Services Are Provided Offsite To Residents
  • Diagnostic Xray Services Are Provided Onsite To Residents
  • Dietary Services Are Provided Onsite To Residents
  • Housekeeping Services Are Provided Onsite To Residents
  • Mental Health Services Are Provided Onsite To Residents
  • Nursing Services Are Provided Onsite To Residents
  • Occupational Therapy Services Are Provided Onsite To Residents
  • Pharmacy Services Are Provided Onsite To Residents
  • Physical Therapy Services Are Provided Onsite To Residents
  • Physician Extender Services Are Provided Onsite To Residents
  • Physician Services Are Provided Onsite To Residents
  • Podiatry Services Are Provided Onsite To Residents
  • Social Work Services Are Provided Onsite To Residents
  • Speech/Language Pathology Services Are Provided Onsite To Residents
  • Therapeutic Recreation Specialist Services Are Provided Onsite To Residents
  • Vocational Services Are Provided Offsite To Residents

Staff Information

Number of Registered Nurses Hours Per Resident Per Day
This Nursing Home:

1.310
State:

0.914
Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day
This Nursing Home:

0.720
State:

0.722
Total Number of Licensed Staff Hours Per Resident Per Day
Here:

2.020
State:

1.632
Number of ,Certified Nurse Assistant Hours Per Resident Per Day
This Nursing Home:

0.110
State:

0.109
Number Therapy Hours Per Resident Per Day
This Nursing Home:

0.110
Colorado:

0.118

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased
Here:

3.9%
Colorado:

15.7%
Percent of long-stay residents who self-report moderate to severe pain
Here:

3.7%
State:

12.4%
Percent of long-stay high-risk residents with pressure ulcers
This Nursing Home:

1.1%
State:

5.2%
Percent of long-stay residents who lose too much weight
This Nursing Home:

8.8%
State:

7.7%
Percent of long-stay low-risk residents who lose control of their bowels or bladder
This Nursing Home:

16.0%
State:

46.6%
Percent of long-stay residents who have had a catheter inserted and left in their bladder
Here:

9.1%
Colorado:

5.4%
Percent of long-stay residents with a urinary tract infection
Here:

4.8%
Colorado:

7.0%
Percent of long-stay residents who have depressive symptoms
Here:

4.3%
Colorado:

7.1%
Percent of long-stay residents who were physically restrained
This Nursing Home:

2.7%
Colorado:

2.1%
Percent of long-stay residents experiencing one or more falls with major injury
This Nursing Home:

4.1%
State:

4.0%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Here:

61.6%
Colorado:

91.9%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine
Here:

18.2%
State:

91.4%
Percent of short-stay residents who self-report moderate to severe pain
This Nursing Home:

14.0%
State:

24.1%
Percent of short-stay residents with Pressure ulcers that are new or worsened
Here:

3.8%
State:

1.5%
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Here:

76.7%
Colorado:

83.9%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine
Here:

43.4%
Colorado:

78.2%
Percent of long-stay residents who received an antipsychotic medication
Here:

26.6%
State:

20.4%

Complaint Deficiency

An approved automatic sprinkler system connected to the fire alarm system: Few (Minimal harm or potential for actual harm)

Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed: Few (Minimal harm or potential for actual harm)

Proper medical gas storage and administration areas: Few (Minimal harm or potential for actual harm)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Some (Minimal harm or potential for actual harm)

Keep each resident free from physical restraints, unless needed for medical treatment: Some (Minimal harm or potential for actual harm)

A separate and independent backup electrical power source: Few (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Some (Minimal harm or potential for actual harm)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Few (Minimal harm or potential for actual harm)

Other fire safety features required by fire safety codes: Some (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Few (Minimal harm or potential for actual harm)

Review or revise the resident's care plan after any major change in a resident's physical or mental health: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Proper backup exit lighting: Few (Immediate jeopardy to resident health or safety)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Minimal harm or potential for actual harm)

Post nurse staffing information/data on a daily basis: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Minimal harm or potential for actual harm)

Hire sufficient dietary support personnel: Few (Minimal harm or potential for actual harm)

Heating and ventilation systems that have been properly installed according to the manufacturer's instructions: Many (Minimal harm or potential for actual harm)

Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay: Some (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Some (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Some (Actual harm)

Fire-resistant room wall surfaces: Some (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property: Few (Minimal harm or potential for actual harm)

Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed: Few (Minimal harm or potential for actual harm)

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Some (Minimal harm or potential for actual harm)

Use a registered nurse at least 8 hours a day, 7 days a week: Some (Minimal harm or potential for actual harm)

Properly hold, secure and manage each resident's personal money which is deposited with the nursing home: Few (Minimal harm or potential for actual harm)

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor: Few (Minimal harm or potential for actual harm)

Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for: Some (Minimal harm or potential for actual harm)

Properly hold, secure and manage each resident's personal money which is deposited with the nursing home: Few (Minimal harm or potential for actual harm)

Determine if it is safe for the resident to self-administer drugs: Few (Minimal harm or potential for actual harm)

Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Some (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Listen to the resident or family groups or act on their complaints or suggestions: Some (Minimal harm or potential for actual harm)

Provide activities to meet the interests and needs of each resident: Some (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Some (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Few (Minimal harm or potential for actual harm)

Provide necessary care and services to maintain the highest well being of each resident : Few (Minimal harm or potential for actual harm)

Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene: Few (Minimal harm or potential for actual harm)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Minimal harm or potential for actual harm)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (Minimal harm or potential for actual harm)

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Many (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Weekly inspections and monthly testing of generators: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Keep each resident free from physical restraints, unless needed for medical treatment: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Few (Minimal harm or potential for actual harm)

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: Some (Minimal harm or potential for actual harm)

Provide activities to meet the interests and needs of each resident: Some (Minimal harm or potential for actual harm)

Provide medically-related social services to help each resident achieve the highest possible quality of life: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Some (Minimal harm or potential for actual harm)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Minimal harm or potential for actual harm)

Make sure each resident receives an accurate assessment by a qualified health professional: Some (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Allow the resident the right to participate in the planning or revision of the resident's care plan: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Few (Minimal harm or potential for actual harm)

Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Few (Immediate jeopardy to resident health or safety)

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: Few (Minimal harm or potential for actual harm)

Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion: Few (Minimal harm or potential for actual harm)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Minimal harm or potential for actual harm)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Many (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Some (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Some (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Some (Minimal harm or potential for actual harm)

Emergency lighting that can last at least 1 1/2 hours: Some (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Some (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Some (Minimal harm or potential for actual harm)

Proper fire barriers, ventilation and signs for the transport of oxygen: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Some (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Provide necessary care and services to maintain the highest well being of each resident : Few (Minimal harm or potential for actual harm)

Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Many (Minimal harm or potential for actual harm)

Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist: Some (Minimal harm or potential for actual harm)

Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors: Some (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Minimal harm or potential for actual harm)

Emergency lighting that can last at least 1 1/2 hours: Few (Minimal harm or potential for actual harm)

Properly located and lighted Exit signs: Few (Minimal harm or potential for actual harm)

Proper fire barriers, ventilation and signs for the transport of oxygen: Few (Minimal harm or potential for actual harm)

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