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Terrace Gardens Health Care Center

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 108
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 01/19/2012

Date of last standard health inspection: 01/19/2012
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 1
Average number of Health Deficiencies in CO: 3
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in CO: 0 - 12
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/04/2012 00/02/2001 2 Few

Inspection, 00/04/2012

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/04/2012 00/02/2001 2 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. 00/04/2012 00/02/2001 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. 00/04/2012 00/02/2001 2 Some
Provide food in a way that meets a resident's needs. 00/04/2012 00/02/2001 2 Some
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents are safe from serious medication errors. 00/04/2012 00/02/2001 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/04/2012 00/02/2001 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/04/2012 00/02/2001 2 Few
Ensure residents maintain acceptable nutritional status. 00/04/2012 00/02/2001 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give the resident's representative the ability to exercise the resident's rights. 00/04/2012 00/02/2001 2 Few
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. 00/04/2012 00/02/2001 2 Some

Inspection, 00/03/2006

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/03/2006 00/06/2007 2 Some
Have enough outside ventilation via a window or mechanical ventilation, or both. 00/03/2006 00/06/2007 2 Many
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) 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. 00/03/2006 00/06/2007 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. 00/03/2006 00/06/2007 2 Some
Store, cook, and serve food in a safe and clean way. 00/03/2006 00/06/2007 2 Many
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/03/2006 00/06/2007 2 Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 00/03/2006 00/06/2007 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 00/03/2006 00/06/2007 2 Some
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/03/2006 00/06/2007 3 Few
Ensure services provided by the nursing facility meet professional standards of quality. 00/03/2006 00/06/2007 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/03/2006 00/06/2007 2 Few
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 00/03/2006 00/06/2007 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/03/2006 00/06/2007 2 Few
Give each resident enough fluids to keep them healthy and prevent dehydration. 00/03/2006 00/06/2007 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/03/2006 00/06/2007 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents a notice of rights, rules, services and charges. 00/03/2006 00/06/2007 2 Some
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. 00/03/2006 00/06/2007 2 Few

Inspection, 01/09/2001

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Post nurse staffing information/data on a daily basis. 01/09/2001 02/03/2003 1 Many
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident. 01/09/2001 02/03/2003 2 Many
Keep clinical record information safe. 01/09/2001 02/03/2003 2 Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 01/09/2001 02/03/2003 2 Many
Post nurse staffing information/data on a daily basis. 01/09/2001 02/03/2003 1 Many
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident. 01/09/2001 02/03/2003 2 Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 01/09/2001 02/03/2003 Many and develop corrective plans of action.
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 01/09/2001 02/03/2003 2 Many
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/09/2001 02/03/2003 4 Some
Dispose of garbage and refuse properly. 01/09/2001 02/03/2003 2 Many
Have a program that investigates, controls and keeps infection from spreading. 01/09/2001 02/03/2003 2 Many
Have enough outside ventilation via a window or mechanical ventilation, or both. 01/09/2001 02/03/2003 2 Some
Provide housekeeping and maintenance services. 01/09/2001 02/03/2003 2 Many
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/09/2001 02/03/2003 4 Some
Dispose of garbage and refuse properly. 01/09/2001 02/03/2003 2 Many
Have a program that investigates 01/09/2001 02/03/2003 Many controls and keeps infection from spreading.
Have enough outside ventilation via a window or mechanical ventilation 01/09/2001 02/03/2003 Some or both.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) 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. 01/09/2001 02/03/2003 3 Few
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. 01/09/2001 02/03/2003 3 Few
Develop and implement policies for 1) screening and training employees; and the 2) prevention 01/09/2001 02/03/2003 investigation identification
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. 01/09/2001 02/03/2003 2 Some
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. 01/09/2001 02/03/2003 2 Some
Store, cook, and serve food in a safe and clean way. 01/09/2001 02/03/2003 2 Many
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. 01/09/2001 02/03/2003 2 Some
Prepare food that is nutritional 01/09/2001 02/03/2003 tasty appetizing
Store 01/09/2001 02/03/2003 and serve food in a safe and clean way. cook
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure 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. 01/09/2001 02/07/2003 2 Some
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 01/09/2001 02/03/2003 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/09/2001 02/07/2003 2 Some
Ensure 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. 01/09/2001 02/07/2003 2 Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/09/2001 02/07/2003 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 01/09/2001 02/03/2003 2 Few
Provide medically-related social services to help each resident achieve the highest possible quality of life. 01/09/2001 02/03/2003 3 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/09/2001 02/07/2003 3 Few
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 01/09/2001 02/03/2003 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 01/09/2001 02/03/2003 3 Some
Ensure 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. 01/09/2001 02/03/2003 2 Few
Ensure residents maintain acceptable nutritional status. 01/09/2001 02/03/2003 2 Few
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 01/09/2001 02/03/2003 2 Some
Use a registered nurse at least 8 hours a day, 7 days a week. 01/09/2001 02/03/2003 2 Few
Give or get specialized rehabilitative services per the patient's assessment or plan of care. 01/09/2001 02/03/2003 2 Few
Provide activities to meet the interests and needs of each resident. 01/09/2001 02/03/2003 2 Few
Provide medically-related social services to help each resident achieve the highest possible quality of life. 01/09/2001 02/03/2003 3 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/09/2001 02/07/2003 3 Few
Assist those residents who need help with eating/drinking 01/09/2001 02/03/2003 Few grooming and personal and oral hygiene.
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 01/09/2001 02/03/2003 3 Some
Ensure that each resident who enters the nursing home without a catheter is not given a catheter 01/09/2001 02/03/2003 and that incontinent patients receive proper servi unless medically necessary
Ensure residents maintain acceptable nutritional status. 01/09/2001 02/03/2003 2 Few
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 01/09/2001 02/03/2003 2 Some
Use a registered nurse at least 8 hours a day 01/09/2001 02/03/2003 Few 7 days a week.
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure each resident receives an accurate assessment by a qualified health professional. 01/09/2001 02/03/2003 2 Few
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 01/09/2001 02/03/2003 2 Some
Allow residents the right to participate in the planning or revision of care and treatment. 01/09/2001 02/03/2003 2 Few
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. 01/09/2001 02/03/2003 2 Some
Develop a complete care plan that meets all the resident's needs 01/09/2001 02/03/2003 Some with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment. 01/09/2001 02/03/2003 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. 01/09/2001 02/03/2003 2 Few
Give residents a notice of rights, rules, services and charges. 01/09/2001 02/03/2003 2 Some
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 01/09/2001 02/03/2003 2 Few
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. 01/09/2001 02/03/2003 2 Few
Try to resolve each resident's complaints quickly. 01/09/2001 02/03/2003 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/09/2001 02/03/2003 2 Some
Give notice to the resident before a room or roommate change. 01/09/2001 02/03/2003 2 Few
Immediately tell the resident 01/09/2001 02/03/2003 and a family member of situations (injury/decline/ the resident's doctor
Try to resolve each resident's complaints quickly. 01/09/2001 02/03/2003 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/09/2001 02/03/2003 2 Some

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in CO Golden Living Center, Asheville
RN Staff Only1 N/A N/A 4 out of 5 stars
Total Number of Residents 86 73 80
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 17 hours 54 minutes 1 hour 22 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 17 hours 10 minutes 45 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 16 hours 58 minutes 37 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 18 hours 39 minutes 1 hour 51 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 02/07/2012

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 02/07/2012
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in CO: 0
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in CO: 0 - 0

Inspection, 01/09/2012

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 01/09/2012 01/04/2001 2 Few
Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. 01/09/2012 01/07/2001 2 Some
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Weekly inspections and monthly testing of generators. 01/09/2012 01/08/2001 2 Few
Properly installed electrical wiring and equipment. 01/09/2012 01/07/2001 2 Few
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Record of quarterly fire drills for each shift under varying conditions. 01/09/2012 02/00/2001 2 Few
Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are accessible at all times. 01/09/2012 01/07/2001 2 Some
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are free from obstructions and can be used at all times. 01/09/2012 01/07/2001 2 Some
Restrictions on the use of flammable curtains. 01/09/2012 01/07/2001 2 Some
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 01/09/2012 01/07/2001 2 Some
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Emergency lighting that can last at least 1 1/2 hours. 01/09/2012 01/07/2001 2 Few
Smoke Compartmentation and Control Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Smoke barrier doors that can resist smoke for at least 20 minutes. 01/09/2012 01/07/2001 2 Some

Inspection, 00/01/2007

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 00/01/2007 01/02/2007 2 Few
Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridors that are separated from use areas by walls constructed to limit the passage of smoke. 00/01/2007 01/03/2007 2 Few
Corridor and hallway doors that block smoke. 00/01/2007 00/01/2007 2 Few
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 00/01/2007 00/03/2008 2 Few
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 00/01/2007 01/04/2007 2 Few
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper medical gas storage and administration areas. 00/01/2007 00/01/2007 2 Few

Inspection, 00/07/2002

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 00/07/2002 00/09/2002 2 Few
Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 00/07/2002 03/01/2003 2 Few
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 00/07/2002 02/09/2002 2 Few
Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are accessible at all times. 00/07/2002 01/09/2003 2 Few
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 00/07/2002 02/09/2003 2 Few
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly located and lighted Exit" signs." 00/07/2002 03/01/2003 2 Few
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper fire barriers, ventilation and signs for the transfilling of oxygen. 00/07/2002 02/09/2002 2 Few
Miscellaneous Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Other fire safety features required by fire safety codes. 00/07/2002 03/01/2003 2 Few
 

2438 Fountain Boulevard
Colorado Springs, CO 80910

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