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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
Residents77
Percent Occupied81%
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 4 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 29, 2016 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential 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.
ESomePotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
ESomePotential 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 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 InspectionProvide special eating equipment and utensils for each resident who needs them.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
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 InspectionProvide activities to meet the interests and needs of each resident.
DFewPotential for HarmHealth 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 HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .

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.

April 8, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$2,275 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 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 30min
2hr 10min
ReportedExpected
CNA
40min
35min
ReportedExpected
LPN
50min
50min
ReportedExpected
RN
4hr 5min
3hr 35min
ReportedExpected
Total Nursing

This facility also provides approximately 10min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

97.4%
66.3%
66.3%
66.3%
92.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
98.7%
88.8%
95.8%
98.7%
89.1%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
45.5%
44.6%
41.2%
35.1%
48.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of low risk long-stay residents who lose control of their bowels or bladder
18.7%
18.1%
15.4%
17.4%
17.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who received an antianxiety or hypnotic medication
14.6%
11.8%
7.7%
12.5%
17.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents whose ability to move independently worsened
41.4%
42.4%
43.4%
39.6%
14.9%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who received an antipsychotic medication
6.8%
8.5%
6.3%
10.4%
15.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents whose need for help with daily activities has increased
1.6%
1.5%
0.0%
0.0%
9.2%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who self-report moderate to severe pain
5.1%
2.5%
0.0%
4.0%
7.2%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who lose too much weight
6.4%
10.9%
0.0%
5.3%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of high risk long-stay residents with pressure ulcers
6.5%
5.1%
2.9%
2.8%
4.3%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who have depressive symptoms
0.0%
1.2%
0.0%
0.0%
3.5%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents with a urinary tract infection
2.5%
2.5%
2.8%
1.3%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents experiencing one or more falls with major injury
0.0%
1.2%
1.3%
1.2%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents with a catheter inserted and left in their bladder
1.3%
1.2%
0.0%
1.3%
0.6%
Q4 2015Q1 2016Q2 2016Q3 2016CO
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

-
-
85.2%
71.4%
75.0%
Q4 2015Q1 2016Q2 2016Q3 2016CO
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
72.4%
-
-
-
74.3%
Q4 2015Q1 2016Q2 2016Q3 2016CO
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
65.3%
Q4 2015Q1 2016Q2 2016Q3 2016CO
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
-
4.8%
4.0%
18.8%
Q4 2015Q1 2016Q2 2016Q3 2016CO
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
-
-
-
-
1.7%
Q4 2015Q1 2016Q2 2016Q3 2016CO
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
-
-
8.9%
0.0%
1.1%
Q4 2015Q1 2016Q2 2016Q3 2016CO
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents with pressure ulcers that are new or worsened