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Mission San Miguel Nursing & Rehabilitation Center

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 95
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: 12/05/2011

Date of last standard health inspection: 12/05/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 12
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. 00/05/2012 00/06/2001 2 Some
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 00/05/2012 00/06/2001 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Help and prepare each resident for a safe and easy discharge or transfer from the nursing home. 00/05/2012 00/06/2001 2 Few
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. 00/01/2012 00/04/2001 3 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 00/01/2012 00/04/2001 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
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. 00/01/2012 00/04/2001 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 00/01/2012 00/04/2001 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/01/2012 00/04/2001 2 Few
Assist those residents who need help with eating/drinking 00/01/2012 00/04/2001 Few grooming and personal and oral hygiene.
Provide or obtain dental services for each resident. 00/01/2012 00/04/2001 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 00/01/2012 00/04/2001 Few with timetables and actions that can be measured.
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. 00/01/2012 00/04/2001 2 Some

Inspection, 00/05/2012

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 00/05/2012 00/06/2001 2 Few
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. 00/05/2012 00/06/2001 2 Some
Have a program that investigates, controls and keeps infection from spreading. 00/05/2012 00/06/2001 2 Some
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. 00/05/2012 00/06/2001 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/05/2012 00/06/2001 2 Many
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. 00/05/2012 00/06/2001 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 00/05/2012 00/06/2001 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/05/2012 00/06/2001 2 Few
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 00/05/2012 00/06/2001 2 Few
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. 00/05/2012 00/06/2001 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Conduct initial and periodic assessments of each resident's functional capacity. 00/05/2012 00/06/2001 2 Few
Ensure each resident receives an accurate assessment by a qualified health professional. 00/05/2012 00/06/2001 2 Few
Allow residents the right to participate in the planning or revision of care and treatment. 00/05/2012 00/06/2001 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. 00/05/2012 00/06/2001 1 Many
Help and prepare each resident for a safe and easy discharge or transfer from the nursing home. 00/05/2012 00/06/2001 2 Few

Inspection, 01/06/2006

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure the activities program is directed by a qualified professional. 01/06/2006 02/04/2008 2 Some
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident. 01/06/2006 02/04/2008 2 Many
Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. 01/06/2006 02/04/2008 2 Many
Keep accurate 01/06/2006 02/04/2008 Few complete and organized clinical records on each re
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 01/06/2006 02/04/2008 Many and develop corrective plans of action.
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide a safe 01/06/2006 02/04/2008 comfortable and home-like environment; and allow r clean
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/06/2006 02/04/2008 4 Some
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Protect each resident from all abuse 01/06/2006 02/04/2008 and involuntary separation from others. physical punishment
1) Hire only people with no legal history of abusing 01/06/2006 02/04/2008 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Develop and implement policies for 1) screening and training employees; and the 2) prevention 01/06/2006 02/04/2008 investigation identification
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 01/06/2006 02/04/2008 2 Some
Provide medically-related social services to help each resident achieve the highest possible quality of life. 01/06/2006 02/04/2008 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/06/2006 02/04/2008 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Allow residents the right to participate in the planning or revision of care and treatment. 01/06/2006 02/04/2008 2 Few
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. 01/06/2006 02/04/2008 2 Some
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. 01/06/2006 02/04/2008 2 Few
Immediately tell the resident 01/06/2006 02/04/2008 and a family member of situations (injury/decline/ the resident's doctor

Inspection, 02/00/2005

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. 02/00/2005 01/01/2008 2 Some
Provide or obtain laboratory services only when ordered by the attending physician. 02/00/2005 01/01/2008 2 Few
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 02/00/2005 02/03/2006 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/00/2005 01/01/2008 3 Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 02/00/2005 02/03/2006 2 Many
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/00/2005 02/03/2006 3 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep each resident free from physical restraints, unless needed for medical treatment. 02/00/2005 02/03/2006 2 Few
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. 02/00/2005 01/01/2008 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 02/00/2005 02/03/2006 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. 02/00/2005 02/03/2006 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 02/00/2005 02/03/2006 2 Some
Provide medically-related social services to help each resident achieve the highest possible quality of life. 02/00/2005 01/01/2008 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 02/00/2005 01/01/2008 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/00/2005 01/01/2008 3 Few
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. 02/00/2005 02/03/2006 2 Few
Ensure 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. 02/00/2005 02/03/2006 2 Few
Ensure residents maintain acceptable nutritional status. 02/00/2005 02/03/2006 2 Few
Give each resident enough fluids to keep them healthy and prevent dehydration. 02/00/2005 02/03/2006 2 Few
Provide medically-related social services to help each resident achieve the highest possible quality of life. 02/00/2005 02/03/2006 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 02/00/2005 02/03/2006 2 Some
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/00/2005 02/03/2006 3 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assure that each resident 02/00/2005 02/03/2006 2 Few
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 02/00/2005 02/03/2006 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. 02/00/2005 02/03/2006 2 Few
Give residents a notice of rights, rules, services and charges. 02/00/2005 02/03/2006 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. 02/00/2005 02/03/2006 2 Some
1) Protect residents from being forced to work at the nursing home 02/00/2005 01/01/2008 Few or 2) let residents work if they want to.

Inspection, 00/04/2004

Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide residents with private access to a telephone. 00/04/2004 00/02/2005 2 Some
Provide care for each resident in a way that maintains or improves their quality of life. 00/04/2004 00/02/2005 2 Some
Reasonably accommodate the needs and preferences of each resident. 00/04/2004 00/02/2005 2 Few

Inspection, 02/03/2003

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. 02/03/2003 02/02/2004 3 Few
Have a program that investigates 02/03/2003 02/02/2004 Some controls and keeps infection from spreading.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 02/03/2003 02/04/2008 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
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. 02/03/2003 02/04/2008 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 02/03/2003 02/02/2004 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 02/03/2003 02/04/2008 3 Few
Properly care for residents needing special services 02/03/2003 02/04/2008 colostomy including: injections
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 02/03/2003 02/02/2004 Few with timetables and actions that can be measured.
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Help and prepare each resident for a safe and easy discharge or transfer from the nursing home. 02/03/2003 02/02/2004 2 Few

Inspection, 00/03/2002

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 00/03/2002 00/05/2003 Few complete and organized clinical records on each re
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 00/03/2002 00/05/2003 2 Some
Provide clean bed and bath linens that are in good condition. 00/03/2002 00/05/2003 2 Some
Maintain comfortable and safe temperature levels. 00/03/2002 00/05/2003 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/03/2002 00/05/2003 2 Some
Have enough outside ventilation via a window or mechanical ventilation 00/03/2002 00/05/2003 Some or both.
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/03/2002 00/05/2003 2 Some
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Permit residents to remain in the facility and not be transferred or discharged without adequate reason. 00/03/2002 00/05/2003 2 Few
Provide timely notification to the resident before transfer or discharge. 00/03/2002 00/05/2003 2 Few

Inspection, 03/00/2001

Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. 03/00/2001 02/02/2002 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. 03/00/2001 02/02/2002 2 Few

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 67
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 17 hours 54 minutes 1 hour 41 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 17 hours 10 minutes 47 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 16 hours 58 minutes 54 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 18 hours 39 minutes 3 hours 23 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: 12/20/2011

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 12/20/2011
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, 02/00/2012

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. 02/00/2012 01/07/2001 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. 02/00/2012 01/07/2001 2 Few
Smoking Regulations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Posted No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed." 02/00/2012 01/07/2001 2 Few

Inspection, 01/05/2006

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 01/05/2006 01/06/2006 2 Few
Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 01/05/2006 00/06/2007 2 Few
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. 01/05/2006 01/06/2006 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. 01/05/2006 01/06/2006 2 Some
Miscellaneous Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Other fire safety features required by fire safety codes. 01/05/2006 00/06/2007 2 Few

Inspection, 01/09/2002

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 01/09/2002 00/05/2003 2 Few
Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly protected cooking facilities. 01/09/2002 00/01/2005 2 Few
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 01/09/2002 02/04/2004 2 Few
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
A written emergency evacuation plan. 01/09/2002 00/01/2005 2 Some
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Restrictions on the use of flammable curtains. 01/09/2002 00/01/2005 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. 01/09/2002 00/01/2005 2 Some
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper medical gas storage and administration areas. 01/09/2002 02/04/2004 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. 01/09/2002 00/01/2005 2 Some
 

7150 Poplar Street
Commerce City, CO 80022

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