5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Florence, CO
1-star overall rating with 1-star inspections with abuse icon flag with 5 recent health deficiencies
903 Moore Dr, Florence, CO
(719) 784-6331
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
105
Certified beds
Average residents
60
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.86
Registered nurse staffing
LPN hours / resident day
0.04
Licensed practical nurse staffing
Aide hours / resident day
1.51
Nurse aide staffing
Weekend hours
2.04
Weekend nurse staffing
RN turnover
72%
Annual RN turnover
Total nurse turnover
69%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
93.5%
7.8 pts worse
|
93.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.7%
3.5 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.4%
2.1 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
7.4%
4.5 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.0%
0.8 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
11.2%
3.7 pts worse
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.8% |
20.6%
2.2 pts worse
|
16.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.3% |
15.2%
5.1 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.2% |
14.6%
13.6 pts worse
|
14.9%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.8%
1.3 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.5%
1.3 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
22.4%
2.5 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
3.7%
0.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.4% |
76.4%
8 pts worse
|
81.7%
13.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-30
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2020-08-13
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2020-08-13
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-08-13
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-09-16
Fire Safety
Have properly spaced exits within rooms.
Corrected 2020-09-18
Fire Safety
Construct fire resistant interior walls.
Corrected 2020-09-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-10-29
Fire Safety
Provide large enough exits.
Corrected 2020-09-18
Fire Safety
Install resident room doors of proper design and width.
Corrected 2020-09-18
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2020-09-18
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-09-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-09-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-09-16
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2020-09-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-09-18
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-09-24
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
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.
Not marked corrected
Health
Provide activities to meet all resident's needs.
Not marked corrected
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-25
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-25
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-25
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-08-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-08-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-08-13
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-08-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-08-13
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-08-13
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-08-13
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-08-13
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-08-13
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
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