Terrace Gardens Healthcare Center Colorado Springs

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

December 9, 2020 - 11 months ago

	Residents Affected	Severity	Source/Type	View Full Report Description
F	Many	Potential for Harm	Health Inspection	Infection Control Deficiencies: Provide and implement an infection prevention and control program.

April 29, 2020 - 2 years ago

	Residents Affected	Severity	Source/Type	View Full Report Description
E	Some	Potential for Harm	Health Inspection	Infection Control Deficiencies: Provide and implement an infection prevention and control program.

July 24, 2019 - 2 years ago

	Residents Affected	Severity	Source/Type	View Full Report Description
F	Many	Potential for Harm	Health Inspection	Nursing and Physician Services Deficiencies: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
E	Some	Potential for Harm	Health Inspection	Pharmacy Service Deficiencies: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
E	Some	Potential for Harm	Health Inspection	Nutrition and Dietary Deficiencies: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D	Few	Potential for Harm	Health Inspection	Resident Rights Deficiencies: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
D	Few	Potential for Harm	Health Inspection	Resident Rights Deficiencies: Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave.
D	Few	Potential for Harm	Health Inspection	Resident Assessment and Care Planning Deficiencies: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D	Few	Potential for Harm	Health Inspection	Resident Assessment and Care Planning Deficiencies: Ensure services provided by the nursing facility meet professional standards of quality.
D	Few	Potential for Harm	Health Inspection	Quality of Life and Care Deficiencies: Provide activities to meet all resident's needs.
D	Few	Potential for Harm	Health Inspection	Quality of Life and Care Deficiencies: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
D	Few	Potential for Harm	Health Inspection	Quality of Life and Care Deficiencies: Provide routine and 24-hour emergency dental care for each resident.

May 14, 2019 - 3 years ago

	Residents Affected	Severity	Source/Type	View Full Report Description
D	Few	Potential for Harm	Complaint	Quality of Life and Care Deficiencies: Provide appropriate treatment and care according to orders, resident's preferences and goals.

January 15, 2019 - 3 years ago

	Residents Affected	Severity	Source/Type	View Full Report Description
D	Few	Potential for Harm	Complaint	Resident Rights Deficiencies: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
D	Few	Potential for Harm	Complaint	Quality of Life and Care Deficiencies: Provide care and assistance to perform activities of daily living for any resident who is unable.

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 Healthcare 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	1hr 60min
Reported	Expected
CNA

35min	45min
Reported	Expected
LPN

55min	30min
Reported	Expected
RN

3hr 30min	3hr 15min
Reported	Expected
Total Nursing

This facility also provides approximately 45min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

59.5%
59.5%
61.3%
61.3%
95.3%
96.1%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine

100.0%
98.3%
100.0%
100.0%
91.5%
94.1%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine

23.1%
23.7%
31.1%
25.6%
47.8%
48.1%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of low risk long-stay residents who lose control of their bowels or bladder

18.2%
13.8%
17.2%
16.9%
12.0%
19.5%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents who received an antianxiety or hypnotic medication

6.1%
4.1%
14.0%
24.5%
18.2%
18.5%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents whose ability to move independently worsened

7.3%
7.1%
12.5%
19.0%
15.2%
15.0%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents whose need for help with daily activities has increased

19.6%
16.1%
12.5%
20.3%
15.3%
14.0%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents who received an antipsychotic medication

3.1%
0.0%
5.3%
10.3%
6.0%
7.4%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of high risk long-stay residents with pressure ulcers

0.0%
1.7%
0.0%
0.0%
3.6%
6.1%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents who have depressive symptoms

5.5%
1.8%
6.3%
0.0%
6.0%
5.9%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents who lose too much weight

3.3%
0.0%
0.0%
0.0%
3.6%
3.4%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents experiencing one or more falls with major injury

0.0%
0.0%
0.0%
3.0%
1.9%
2.5%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents with a urinary tract infection

0.0%
0.0%
0.0%
1.6%
1.7%
1.6%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents with a catheter inserted and left in their bladder

0.0%
0.0%
0.0%
0.0%
0.1%
0.2%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

100.0%
100.0%
100.0%
100.0%
78.8%
83.7%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine

74.3%
74.3%
89.6%
89.6%
79.2%
82.6%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine

-
-
-
-
68.2%
69.0%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

* The data for this facility for some quarters is unavailable.

Percentage of short-stay residents who made improvements in function

0.0%
-
-
-
1.8%
1.8%

Q3 2019 Q4 2019 Q1 2020 Q2 2020 CO U.S.

* The data for this facility for some quarters is unavailable.

Percentage of short-stay residents who newly received an antipsychotic medication

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