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Elms Haven Center

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About Elms Haven Center

General Information

Legal Business Name12080 Bellaire Way Operations LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJanuary 1, 1988 (29 years)
Capacity242
Residents207
Percent Occupied86%
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 Elms Haven Center

Elms Haven 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 2, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintEnsure that residents are safe from serious medication errors.
GFewActual HarmComplaintEnsure residents maintain acceptable nutritional status.
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

March 31, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure 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.

November 24, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
FManyPotential for HarmFire Safety InspectionA written emergency evacuation plan.
ESomePotential for HarmFire Safety InspectionRestrictions on the use of flammable curtains.
DFewPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
DFewPotential for HarmFire Safety InspectionAn externally vented heating system.
DFewPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
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 InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
DFewPotential for HarmFire Safety InspectionFire resistant interior walls.
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 InspectionOther fire safety features required by fire safety codes.
DFewPotential for HarmFire Safety InspectionProper medical gas storage and administration areas.
DFewPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.

October 27, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionHave enough outside ventilation via a window or mechanical ventilation, or both.
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaint+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 InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.

August 12, 2014 - 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.

July 23, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide housekeeping and maintenance services.
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential 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.

May 7, 2014 - 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.
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

January 9, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionRestrictions on the use of flammable curtains.
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
FManyPotential 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 InspectionProper medical gas storage and administration areas.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionProperly protected cooking facilities.
DFewPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
DFewPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
DFewPotential for HarmFire Safety InspectionProper stairway enclosures and vertical shafts.
DFewPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

December 12, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionKeep all essential equipment working safely.
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential 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.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
CManyPotential for Minimal HarmHealth InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
DFewPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
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 InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Elms Haven 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 10min
2hr 25min
ReportedExpected
CNA
1hr
45min
ReportedExpected
LPN
35min
1hr 5min
ReportedExpected
RN
3hr 45min
4hr 15min
ReportedExpected
Total Nursing

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

Quality Measures for Long Stay Residents

91.1%
90.4%
90.4%
94.5%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Seasonal Influenza Vaccine
83.3%
84.9%
85.7%
91.0%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
37.5%
32.7%
36.1%
49.8%
Q1 2015Q2 2015Q3 2015CO
Low Risk Residents Who Lose Control of Their Bowel or Bladder
21.8%
21.3%
16.2%
15.8%
Q1 2015Q2 2015Q3 2015CO
Received an Antipsychotic Medication
15.3%
18.4%
16.3%
15.4%
Q1 2015Q2 2015Q3 2015CO
Need for Help with ADLs has Increased
10.4%
16.2%
17.2%
10.2%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
11.9%
8.2%
7.2%
8.3%
Q1 2015Q2 2015Q3 2015CO
Lose Too Much Weight
1.6%
2.7%
3.6%
4.4%
Q1 2015Q2 2015Q3 2015CO
High Risk Residents With Pressure Ulcers
8.9%
4.2%
7.6%
4.4%
Q1 2015Q2 2015Q3 2015CO
Have Depressive Symptoms
3.4%
3.5%
5.5%
4.1%
Q1 2015Q2 2015Q3 2015CO
With a Urinary Tract Infection
2.8%
1.7%
3.3%
3.8%
Q1 2015Q2 2015Q3 2015CO
Experiencing One or More Falls with Major Injury
3.9%
0.8%
1.3%
3.6%
Q1 2015Q2 2015Q3 2015CO
With a Catheter Inserted and Left in Their Bladder
5.6%
4.7%
2.2%
0.8%
Q1 2015Q2 2015Q3 2015CO
Were Physically Restrained

Quality Measures for Short Stay Residents

81.4%
85.4%
81.2%
76.2%
Q1 2015Q2 2015Q3 2015CO
Assessed and Appropriately Given the Pneumococcal Vaccine
80.9%
81.2%
81.3%
77.6%
Q1 2015Q2 2015Q3 2015CO
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
21.9%
23.2%
17.6%
19.9%
Q1 2015Q2 2015Q3 2015CO
Self Report Moderate to Severe Pain
0.9%
0.0%
1.6%
1.8%
Q1 2015Q2 2015Q3 2015CO
Newly Received an Antipsychotic Medication
0.0%
1.1%
1.1%
1.0%
Q1 2015Q2 2015Q3 2015CO
With Pressure Ulcers That Are New or Worsened