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PIKES PEAK CARE AND REHABILITATION CENTER - COLORADO SPRINGS, CO

 



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Address
2719 NORTH UNION BOULEVARD
COLORADO SPRINGS, CO, 80909
Phone (make sure to verify first before calling): (719) 636-1676

Number of Certified Beds: 210
Total Number of Residents: 190
Percent of Occupied Beds: 90%
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: Resident
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: 3 Stars
Quality Measures Star Rating: 2 Stars
RN Only Star Rating: 3 Stars

Employment Full-Time Equivalent

Administrative Staff - Full Time: 2.86
Certified Nurse Aides - Full Time: 66.56
Food Service Personnel - Full Time: 1.83
Housekeeping Personnel - Full Time: 5.71
Licensed Practical/ Vocational Nurses - Full Time: 35.73
Medical Directors - Under Contract: 0.09
Mental Health Services Personnel - Under Contract: 0.40
Nurses With Administrative Duties - Full Time: 6.86
Occupational Therapy Aides - Full Time: 0.73
Persons Not Included In Any Other Categories - Full Time: 3.43
Registered Nurses - Full Time: 5.44
Rn Director Of Nursing - Full Time: 1.14
Social Workers - Full Time: 1.14
Activities Professionals - Full Time: 1.14
Dentists - Under Contract: 0.11
Food Service Personnel - Under Contract: 1.37
Podiatrists - Under Contract: 0.11
Housekeeping Personnel - Under Contract: 0.34
Other Physicians - Under Contract: 0.11
Registered Nurses - Under Contract: 2.31
Dietitians - Full Time: 1.14
Sppech Pathologists - Full Time: 0.90
Occupational Therapists - Full Time: 1.10
Physical Therapists - Full Time: 1.34
Occupational Therapy Assistants - Full Time: 0.77
Physical Therapy Aide - Full Time: 0.81
Licensed Practical/ Vocational Nurses - Under Contract: 2.10
Certified Nurse Aides - Under Contract: 5.96

Provided Services

  • Activities Services Are Provided Onsite To Residents
  • Clinical Laboratory 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 Offsite To Residents
  • Dietary Services Are Provided Onsite To Residents
  • Housekeeping Services Are Provided Onsite To Residents
  • Mental Health Services Are Provided Offsite To Residents
  • Mental Health Services Are Provided Onsite To Residents
  • Nursing Services Are Provided Offsite To Residents
  • Nursing Services Are Provided Onsite To Residents
  • Occupational Therapy Services Are Provided Offsite To Residents
  • Occupational Therapy Services Are Provided Onsite To Residents
  • Pharmacy Services Are Provided Offsite To Residents
  • Pharmacy Services Are Provided Onsite To Residents
  • Physical Therapy Services Are Provided Offsite To Residents
  • Physical Therapy Services Are Provided Onsite To Residents
  • Physician Extender Services Are Provided Offsite To Residents
  • Physician Extender Services Are Provided Onsite To Residents
  • Physician Services Are Provided Offsite 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 Offsite To Residents
  • Speech/Language Pathology Services Are Provided Onsite To Residents

Quality Measures

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

20.8%
Colorado:

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

28.1%
Colorado:

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

5.8%
State:

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

9.6%
Colorado:

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

60.2%
State:

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

1.9%
State:

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

3.8%
Colorado:

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

0.6%
Colorado:

7.1%
Percent of long-stay residents who were physically restrained
Here:

5.7%
State:

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

4.4%
State:

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

84.2%
Colorado:

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

89.9%
Colorado:

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

48.6%
Colorado:

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

1.1%
Colorado:

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

51.7%
Colorado:

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

49.4%
State:

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

1.5%
Colorado:

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

23.0%
State:

20.4%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day
Here:

0.620
Colorado:

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

0.830
Colorado:

0.722
Total Number of Licensed Staff Hours Per Resident Per Day
This Nursing Home:

1.450
State:

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

0.080
Colorado:

0.109
Number Therapy Hours Per Resident Per Day
Here:

0.080
Colorado:

0.118

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 (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (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)

Be administered in an acceptable way that maintains the well-being of each resident : Some (Minimal harm or potential for actual harm)

Properly constructed piped-in oxygen systems: Many (Minimal harm or potential for actual harm)

Did not have a written emergency evacuation plan: Some (Minimal harm or potential for actual harm)

Portable fire extinguishers: 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)

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

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)

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 (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 (Immediate jeopardy to resident health or safety)

Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' 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)

Construction that can resist fire for one hour or an approved fire extinguishing system: Some (Potential for minimal harm)

Properly installed electrical wiring and equipment: 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)

Conduct initial and periodic assessments of each resident's functional capacity: 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 (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 (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: 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)

Provide adequate and comfortable lighting levels in all areas: Few (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)

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 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)

Approved construction type or materials: 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)

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)

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)

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

Let the resident or the resident's legal representative the right to access or purchase copies of all records: 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: 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)

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: Few (Minimal harm or potential for actual harm)

Provide activities to meet the interests and needs of each resident: Few (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)

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: Few (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: 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: 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 : Some (Actual harm)

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

Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion unless it was unavoidable: Few (Immediate jeopardy to resident health or safety)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Immediate jeopardy to resident health or safety)

Give each resident enough fluids to keep them healthy and prevent dehydration: 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)

Have enough nurses to care for every resident in a way that maximizes the resident's well being: Some (Minimal harm or potential for actual harm)

Post nurse staffing information/data on a daily basis: Some (Potential for minimal 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)

Dispose of garbage and refuse properly: 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: 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: Some (Minimal harm or potential for actual harm)

1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation: Some (Minimal harm or potential for actual harm)

Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs: Few (Minimal harm or potential for actual harm)

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action: Some (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)

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) 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: Some (Potential for minimal harm)

Give notice to the resident before a room or roommate change: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Some (Potential for minimal harm)

Conduct initial and periodic assessments of each resident's functional capacity: Few (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)

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 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: 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)

Have a program that investigates, controls and keeps infection from spreading: 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)

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: 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: 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)

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