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ELMS HAVEN CARE AND REHABILITATION CENTER - THORNTON, CO

 



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Address
12080 BELLAIRE WAY
THORNTON, CO, 80241
Phone (make sure to verify first before calling): (303) 450-2700

Number of Certified Beds: 242
Total Number of Residents: 206
Percent of Occupied Beds: 85%
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: 1 Star
Health Inspections Star Rating: 1 Star
Nurse Staffing Star Rating: 2 Stars
Quality Measures Star Rating: 1 Star
RN Only Star Rating: 3 Stars

Employment Full-Time Equivalent

Administrative Staff - Full Time: 25.14
Certified Nurse Aides - Full Time: 76.29
Food Service Personnel - Full Time: 21.00
Licensed Practical/ Vocational Nurses - Full Time: 34.29
Medical Directors - Under Contract: 0.29
Mental Health Services Personnel - Under Contract: 0.29
Nurses With Administrative Duties - Full Time: 6.86
Registered Nurses - Full Time: 12.29
Rn Director Of Nursing - Full Time: 1.14
Social Workers - Full Time: 4.57
Activities Professionals - Full Time: 1.14
Pharmacists - Under Contract: 0.14
Podiatrists - Under Contract: 0.29
Housekeeping Personnel - Under Contract: 19.71
Dietitians - Full Time: 1.14
Sppech Pathologists - Full Time: 1.14
Occupational Therapists - Full Time: 1.14
Physical Therapists - Full Time: 1.14
Occupational Therapy Assistants - Full Time: 1.14

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 Offsite To Residents
  • Dental Services Are Provided Offsite To Residents
  • Diagnostic Xray Services Are Provided Offsite To Residents
  • Dietary Services Are Provided Offsite To Residents
  • Housekeeping Services Are Provided Offsite To Residents
  • Mental Health Services Are Provided Offsite To Residents
  • Nursing Services Are Provided Onsite To Residents
  • Occupational Therapy Services Are Provided Onsite To Residents
  • Pharmacy Services Are Provided Offsite To Residents
  • Physical Therapy Services Are Provided Onsite To Residents
  • Physician Services Are Provided Onsite To Residents
  • Podiatry Services Are Provided Offsite 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

Staff Information

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

0.540
State:

0.914
Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day
Here:

0.830
State:

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

1.360
State:

1.632
Number of ,Certified Nurse Assistant Hours Per Resident Per Day
Here:

0.050
Colorado:

0.109
Number Therapy Hours Per Resident Per Day
Here:

0.050
Colorado:

0.118

Quality Measures

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

18.2%
Colorado:

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

13.1%
Colorado:

12.4%
Percent of long-stay high-risk residents with pressure ulcers
Here:

6.1%
State:

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

8.0%
Colorado:

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

56.9%
Colorado:

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

7.7%
State:

5.4%
Percent of long-stay residents with a urinary tract infection
This Nursing Home:

7.5%
Colorado:

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

5.5%
Colorado:

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

4.0%
State:

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

2.8%
State:

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

93.7%
State:

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

69.9%
Colorado:

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

41.1%
Colorado:

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

5.2%
Colorado:

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

73.9%
State:

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

72.6%
Colorado:

78.2%
Percent of short-stay residents who newly received an antipsychotic medication
This Nursing Home:

3.2%
Colorado:

2.1%
Percent of long-stay residents who received an antipsychotic medication
Here:

28.5%
Colorado:

20.4%

Complaint Deficiency

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 (Immediate jeopardy to resident health or safety)

Restrictions on the use of portable space heaters: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Immediate jeopardy to resident health or safety)

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: Some (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: Some (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: Some (Minimal harm or potential for actual harm)

Restrictions on the use of flammable curtains: Few (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)

Properly installed electrical wiring and equipment: Some (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 (Immediate jeopardy to resident health or safety)

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: Some (Actual harm)

Back-up procedures in place for a faulty automatic sprinkler system: Few (Minimal harm or potential for actual harm)

Properly working alarms on sprinkler valves: Few (Minimal harm or potential for actual harm)

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

A separate and independent backup electrical power source: 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)

1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day: Few (Minimal harm or potential for actual harm)

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

Exits that are accessible at all times: Few (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)

Signs that state that exit doors are to be kept closed: 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 backup exit lighting: Few (Immediate jeopardy to resident health or safety)

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

Proper medical gas storage and administration areas: Some (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)

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

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

Properly constructed linen or trash chutes: 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)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Some (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)

Dispose of garbage and refuse properly: Some (Potential for minimal harm)

Record of quarterly fire drills for each shift under varying conditions: Some (Potential for minimal 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)

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)

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

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

Hire sufficient dietary support personnel: Few (Immediate jeopardy to resident health or safety)

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)

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

Signs that state that exit doors are to be kept closed: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: 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)

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

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: Some (Minimal harm or potential for actual harm)

Reasonably accommodate the needs and preferences 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)

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 each residents' abilities in activities of daily living do not decline, unless unavoidable: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: 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: Some (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)

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses: 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)

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: Some (Minimal harm or potential for actual harm)

Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature: Some (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)

Give or get specialized rehabilitative services per the patient's assessment or plan of care: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Smoke barrier doors that can resist smoke for at least 20 minutes: Few (Minimal harm or potential for actual harm)

A fire alarm system that can be heard throughout the facility: Few (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)

Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed: Few (Minimal harm or potential for actual harm)

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

Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives: 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)

Keep each resident's personal and medical records private and confidential: Some (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)

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: Some (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)

Reasonably accommodate the needs and preferences of each resident: Few (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: Some (Minimal harm or potential for actual harm)

Provide necessary care and services to maintain the highest well being of each resident : Few (Immediate jeopardy to resident health or safety)

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: Some (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)

Give each resident enough fluids to keep them healthy and prevent dehydration: Few (Minimal harm or potential for actual harm)

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses: Few (Minimal harm or potential for actual harm)

Provide food in a way that meets a resident's needs: Some (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)

Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing: Few (Minimal harm or potential for actual harm)

Make sure that doctors visit residents regularly, as required: Some (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: Few (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: Many (Minimal harm or potential for actual harm)

Have enough outside ventilation via a window or mechanical ventilation, or both: Some (Minimal harm or potential for actual harm)

Give or get quality lab services/tests in a timely manner to meet the needs of residents: Few (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Some (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)

Exit stairways and towers that are smoke proof: Few (Minimal harm or potential for actual harm)

Resident room doors of proper design and width: 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)

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)

Heating and ventilation systems that have been properly installed according to the manufacturer's instructions: Few (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)

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

Properly installed electrical wiring and equipment: 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: Some (Potential for minimal harm)

Listen to the resident or family groups or act on their complaints or suggestions: Some (Potential for minimal harm)

Conduct initial and periodic assessments of each resident's functional capacity: 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 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 the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Some (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 (Immediate jeopardy to resident health or safety)

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)

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: Many (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: 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)

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

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

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

Back-up procedures in place for a faulty automatic sprinkler system: Few (Minimal harm or potential for actual harm)

An approved back-up procedure for a faulty fire alarm system: Few (Minimal harm or potential for actual harm)

Other nearby nursing homes

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