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Cheyenne Mountain Center

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About Cheyenne Mountain Center

General Information

Legal Business NamePeak Medical Colorado No. 2, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareDecember 1, 1977 (39 years)
Capacity159
Residents137
Percent Occupied86%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Cheyenne Mountain Center

Cheyenne Mountain Center
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Colorado Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 21, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
ESomePotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

April 24, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionGive notice to the resident before a room or roommate change.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionHire sufficient dietary support personnel.
DFewPotential for HarmComplaint+InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmHealth InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.
DFewPotential for HarmComplaint+InspectionAllow residents to self-administer drugs if determined safe.
DFewPotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth Inspection1) 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.
DFewPotential for HarmHealth InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
DFewPotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmHealth InspectionEnsure residents maintain acceptable nutritional status.

March 6, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 83 days
---Fine$6,468 fine
KSomeImmediate JeopardyComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
GFewActual HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmComplaint+InspectionGive each resident enough fluids to keep them healthy and prevent dehydration.
ESomePotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmComplaint+InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
ESomePotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
ESomePotential for HarmComplaint+InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmComplaint+InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
ESomePotential for HarmComplaint+InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
CManyPotential for Minimal HarmComplaint+InspectionKeep clinical record information safe.
DFewPotential for HarmComplaint+InspectionLet residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.
DFewPotential for HarmHealth InspectionKeep complete, dated laboratory records in the resident's file.
DFewPotential for HarmComplaint+InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmComplaint+InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaint+InspectionProvide or obtain laboratory services only when ordered by the attending physician.
DFewPotential for HarmComplaint+InspectionEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
DFewPotential for HarmComplaint+InspectionEnsure residents maintain acceptable nutritional status.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaint+InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaint+InspectionGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
DFewPotential for HarmComplaint+InspectionConduct initial and periodic assessments of each resident's functional capacity.
DFewPotential for HarmComplaint+InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
BSomePotential for Minimal HarmComplaint+InspectionProvide housekeeping and maintenance services.

December 10, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintListen to the resident groups and act on their complaints and suggestions that affect resident care and life.
ESomePotential for HarmComplaintEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Cheyenne Mountain Center require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

1hr 55min
2hr 20min
ReportedExpected
CNA
40min
45min
ReportedExpected
LPN
50min
1hr 15min
ReportedExpected
RN
3hr 30min
4hr 20min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

85.8%
83.8%
83.8%
94.5%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Seasonal Influenza Vaccine
95.3%
97.2%
99.1%
91.0%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
46.9%
39.6%
37.9%
49.8%
Q1 2015Q2 2015Q3 2015CO
Low Risk Residents Who Lose Control of Their Bowel or Bladder
6.7%
5.8%
7.3%
15.8%
Q1 2015Q2 2015Q3 2015CO
Received an Antipsychotic Medication
16.1%
20.7%
25.3%
15.4%
Q1 2015Q2 2015Q3 2015CO
Need for Help with ADLs has Increased
25.6%
31.7%
33.6%
10.2%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
6.6%
11.4%
9.1%
8.3%
Q1 2015Q2 2015Q3 2015CO
Lose Too Much Weight
9.7%
11.9%
8.8%
4.4%
Q1 2015Q2 2015Q3 2015CO
High Risk Residents With Pressure Ulcers
8.0%
5.0%
4.0%
4.4%
Q1 2015Q2 2015Q3 2015CO
Have Depressive Symptoms
0.0%
0.9%
0.0%
4.1%
Q1 2015Q2 2015Q3 2015CO
With a Urinary Tract Infection
0.9%
2.8%
4.5%
3.8%
Q1 2015Q2 2015Q3 2015CO
Experiencing One or More Falls with Major Injury
4.0%
3.3%
1.9%
3.6%
Q1 2015Q2 2015Q3 2015CO
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.8%
Q1 2015Q2 2015Q3 2015CO
Were Physically Restrained

Quality Measures for Short Stay Residents

89.7%
92.6%
96.0%
76.2%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
91.4%
87.1%
87.1%
77.6%
Q1 2015Q2 2015Q3 2015CO
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
34.3%
41.8%
46.3%
19.9%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
0.7%
1.4%
1.3%
1.8%
Q1 2015Q2 2015Q3 2015CO
Newly Received an Antipsychotic Medication
0.4%
0.5%
1.0%
1.0%
Q1 2015Q2 2015Q3 2015CO
With Pressure Ulcers That Are New or Worsened