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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 (40 years)
Capacity159
Residents136
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

June 2, 2016 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
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 InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

December 28, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

September 21, 2015 - 2 years 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

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.

2hr 5min
2hr 20min
ReportedExpected
CNA
40min
45min
ReportedExpected
LPN
1hr 10min
1hr 10min
ReportedExpected
RN
3hr 60min
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

83.8%
80.6%
80.6%
80.6%
92.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
96.4%
95.8%
97.4%
96.4%
89.1%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
37.9%
48.2%
50.8%
53.1%
48.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of low risk long-stay residents who lose control of their bowels or bladder
20.8%
17.4%
17.9%
16.3%
17.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who received an antianxiety or hypnotic medication
19.9%
34.7%
24.2%
18.0%
17.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents whose ability to move independently worsened
7.4%
9.5%
7.1%
7.3%
14.9%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who received an antipsychotic medication
15.5%
26.0%
20.4%
12.6%
15.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents whose need for help with daily activities has increased
20.8%
24.8%
20.6%
21.0%
9.2%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who self-report moderate to severe pain
9.1%
9.5%
11.3%
8.1%
7.2%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who lose too much weight
8.8%
6.4%
3.9%
7.1%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of high risk long-stay residents with pressure ulcers
3.9%
3.0%
5.1%
3.1%
4.3%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who have depressive symptoms
0.9%
0.9%
0.0%
0.0%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents with a urinary tract infection
4.5%
3.4%
4.3%
3.6%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents experiencing one or more falls with major injury
2.8%
6.2%
2.9%
1.9%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
4.3%
4.3%
2.7%
0.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

91.1%
92.6%
93.2%
86.9%
75.0%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
87.1%
79.5%
79.5%
79.5%
74.3%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
57.8%
41.9%
39.4%
69.0%
65.3%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of short-stay residents who made improvements in function
32.8%
40.3%
56.0%
56.4%
18.8%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
0.0%
0.0%
1.3%
1.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of short-stay residents who newly received an antipsychotic medication
1.5%
1.6%
0.7%
0.7%
1.1%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of short-stay residents with pressure ulcers that are new or worsened