7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Ordway, CO
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
401 Idaho Ave, Ordway, CO
(719) 267-3561
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
44
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.69
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
2.30
Nurse aide staffing
Weekend hours
3.14
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
93.5%
8.1 pts worse
|
93.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
94.7%
2.8 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
7.4%
0.5 pts better
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.0%
1.2 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
11.2%
0.6 pts worse
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
20.6%
1.8 pts worse
|
16.7%
5.7 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 | 5.2% |
15.2%
10 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
14.6%
10.7 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
22.4%
10.5 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 8.8% |
76.4%
67.6 pts worse
|
81.7%
72.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Top issue: Nursing and Physician Services (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-30
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-30
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-30
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-30
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-30
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-04-30
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-04-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-15
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-04-30
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-04-30
Fire Safety
Install resident room doors of proper design and width.
Corrected 2019-11-22
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-11-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-11-22
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-11-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-10-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-10-22
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2018-10-22
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-22
Inspection history
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-25
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-25
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-25
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-25
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-25
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 2024-03-25
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-03-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-11-15
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2019-11-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-07
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2019-11-30
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-11-13
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-07
Health
Implement a program that monitors antibiotic use.
Corrected 2019-11-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-10-05
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-10-05
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-10-05
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2018-10-08
Penalties and ownership
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
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