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Terrace Gardens Health Care Center

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About Terrace Gardens Health Care Center

General Information

Legal Business NameSsc Colorado Springs Terrace Gardens Operating Company LLC
Ownership TypeFor Profit - Limited Liability Company
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJanuary 6, 1983 (34 years)
Capacity108
Residents88
Percent Occupied81%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Terrace Gardens Health Care Center

Terrace Gardens Health Care Center
was reviewed by Medicare to have a rating of 2 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

March 17, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionProper fire barriers, ventilation and signs for the transfilling of oxygen.
ESomePotential for HarmFire Safety InspectionRestrictions on the use of flammable curtains.
ESomePotential for HarmFire Safety InspectionRestrictions on the use of highly flammable decorations.
ESomePotential for HarmFire Safety InspectionApproved construction type or materials.

February 26, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
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.
DFewPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
DFewPotential for HarmComplaint+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 InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
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.

March 25, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
DFewPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionRestrictions on the use of flammable curtains.
DFewPotential for HarmFire Safety InspectionProper fire barriers, ventilation and signs for the transfilling of oxygen.
DFewPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
DFewPotential for HarmFire Safety InspectionHeating and ventilation systems that have been properly installed according to the manufacturer's instructions.
DFewPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
DFewPotential for HarmFire Safety InspectionSmoke barrier doors that can resist smoke for at least 20 minutes.
DFewPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
DFewPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
DFewPotential for HarmFire Safety InspectionApproved construction type or materials.
DFewPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionPortable fire extinguishers.

February 24, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmHealth InspectionGive each resident enough fluids to keep them healthy and prevent dehydration.
DFewPotential for HarmHealth 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 HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmHealth InspectionCoordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
DFewPotential for HarmHealth InspectionLet residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Terrace Gardens Health Care 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.

2hr 5min
2hr 15min
ReportedExpected
CNA
30min
40min
ReportedExpected
LPN
45min
1hr
ReportedExpected
RN
3hr 20min
3hr 60min
ReportedExpected
Total Nursing

Quality Measures for Long Stay Residents

15.9%
15.7%
15.7%
94.5%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Seasonal Influenza Vaccine
98.8%
93.8%
100.0%
91.0%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
40.0%
40.5%
45.7%
49.8%
Q1 2015Q2 2015Q3 2015CO
Low Risk Residents Who Lose Control of Their Bowel or Bladder
21.3%
17.3%
20.5%
15.8%
Q1 2015Q2 2015Q3 2015CO
Received an Antipsychotic Medication
20.8%
21.7%
37.3%
15.4%
Q1 2015Q2 2015Q3 2015CO
Need for Help with ADLs has Increased
19.8%
18.1%
20.7%
10.2%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
1.3%
0.0%
1.1%
8.3%
Q1 2015Q2 2015Q3 2015CO
Lose Too Much Weight
4.2%
10.4%
12.9%
4.4%
Q1 2015Q2 2015Q3 2015CO
High Risk Residents With Pressure Ulcers
17.5%
28.0%
25.9%
4.4%
Q1 2015Q2 2015Q3 2015CO
Have Depressive Symptoms
1.3%
3.8%
1.1%
4.1%
Q1 2015Q2 2015Q3 2015CO
With a Urinary Tract Infection
2.4%
1.2%
0.0%
3.8%
Q1 2015Q2 2015Q3 2015CO
Experiencing One or More Falls with Major Injury
10.2%
11.4%
6.6%
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

100.0%
98.7%
98.5%
76.2%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
65.6%
47.6%
48.8%
77.6%
Q1 2015Q2 2015Q3 2015CO
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
50.7%
35.2%
28.6%
19.9%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
3.8%
2.1%
5.4%
1.8%
Q1 2015Q2 2015Q3 2015CO
Newly Received an Antipsychotic Medication
0.0%
0.0%
0.0%
1.0%
Q1 2015Q2 2015Q3 2015CO
With Pressure Ulcers That Are New or Worsened