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Mission San Miguel Nursing And Rehab Center

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About Mission San Miguel Nursing And Rehab Center

General Information

Legal Business NamePinnacle Health Facilities Xvi, L.P.
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareFebruary 1, 1994 (23 years)
Capacity95
Residents79
Percent Occupied83%
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 Mission San Miguel Nursing And Rehab Center

Mission San Miguel Nursing And Rehab 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

April 2, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionSmoke barrier doors that can resist smoke for at least 20 minutes.
DFewPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.

March 9, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
ESomePotential for HarmHealth InspectionMaintain comfortable and safe temperature levels.
ESomePotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
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 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 InspectionProvide activities to meet the interests and needs of each resident.
DFewPotential for HarmHealth InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
DFewPotential for HarmComplaintProtect a residents' right to refuse some types of non-requested transfers within the nursing home.

January 2, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

May 1, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionHeating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionSmoke barrier doors that can resist smoke for at least 20 minutes.
DFewPotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
DFewPotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
DFewPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
DFewPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
DFewPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
DFewPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.

April 8, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$2,275 fine
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionDispose of garbage and refuse properly.
GFewActual HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
GFewActual HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
GFewActual HarmHealth InspectionEnsure residents maintain acceptable nutritional status.
ESomePotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
ESomePotential for HarmHealth InspectionProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
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 HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmComplaint+InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaint+InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
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 InspectionMake 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.
DFewPotential for HarmHealth InspectionProvide bedrooms that don't allow residents to see each other when privacy is needed.
BSomePotential for Minimal HarmHealth InspectionKeep residents' personal and medical records private and confidential.

December 31, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
GFewActual HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmComplaintProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmComplaintEnsure each resident receives an accurate assessment by a qualified health professional.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Mission San Miguel Nursing And Rehab 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 15min
2hr 25min
ReportedExpected
CNA
40min
35min
ReportedExpected
LPN
40min
60min
ReportedExpected
RN
3hr 35min
4hr
ReportedExpected
Total Nursing

This facility also provides approximately 5min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

98.6%
97.4%
97.4%
94.5%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
100.0%
100.0%
91.0%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
36.4%
43.8%
41.8%
49.8%
Q1 2015Q2 2015Q3 2015CO
Low Risk Residents Who Lose Control of Their Bowel or Bladder
36.7%
36.8%
42.1%
15.8%
Q1 2015Q2 2015Q3 2015CO
Received an Antipsychotic Medication
15.7%
5.6%
6.8%
15.4%
Q1 2015Q2 2015Q3 2015CO
Need for Help with ADLs has Increased
0.0%
0.0%
0.0%
10.2%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
4.3%
9.3%
11.5%
8.3%
Q1 2015Q2 2015Q3 2015CO
Lose Too Much Weight
0.0%
0.0%
2.3%
4.4%
Q1 2015Q2 2015Q3 2015CO
High Risk Residents With Pressure Ulcers
14.9%
2.7%
4.0%
4.4%
Q1 2015Q2 2015Q3 2015CO
Have Depressive Symptoms
1.4%
0.0%
1.3%
4.1%
Q1 2015Q2 2015Q3 2015CO
With a Urinary Tract Infection
2.8%
2.6%
3.8%
3.8%
Q1 2015Q2 2015Q3 2015CO
Experiencing One or More Falls with Major Injury
1.5%
0.0%
0.0%
3.6%
Q1 2015Q2 2015Q3 2015CO
With a Catheter Inserted and Left in Their Bladder
1.4%
1.3%
1.3%
0.8%
Q1 2015Q2 2015Q3 2015CO
Were Physically Restrained

Quality Measures for Short Stay Residents

86.7%
-
-
76.2%
Q1 2015Q2 2015Q3 2015CO
* The data for this facility for some quarters is unavailable.
Assessed and Appropriately Given the Pneumococcal Vaccine
72.4%
72.4%
72.4%
77.6%
Q1 2015Q2 2015Q3 2015CO
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
4.5%
-
-
19.9%
Q1 2015Q2 2015Q3 2015CO
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
-
-
-
1.8%
Q1 2015Q2 2015Q3 2015CO
* The data for this facility for some quarters is unavailable.
Newly Received an Antipsychotic Medication
0.0%
-
-
1.0%
Q1 2015Q2 2015Q3 2015CO
* The data for this facility for some quarters is unavailable.
With Pressure Ulcers That Are New or Worsened