ELMS HAVEN CARE AND REHABILITATION CENTER

The information listed below provides an in-depth look into the type and quality of care offered at Elms Haven Care and Rehabilitation Center. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

ELMS HAVEN CARE AND REHABILITATION CENTER
12080 BELLAIRE WAY
THORNTON, CO 80241
(303) 450-2700

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only

Overall Rating

Percent of Beds Occupied

87%

Number of Residents and Certified Beds

Residents: 210
Certified Beds: 242

This Facility Accepts

Medicare
Medicaid

Operational Details

Operated By For Profit - Corporation
Offers Only Resident Counseling
This Facility is Part of a Chain or Franchise

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Nearby Cities:

Northglenn | Broomfield | Commerce City

Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Elms Haven Care and Rehabilitation Center. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident Services

Resident Conditions

Percent of Service Days

Very High Rehabilitation Plus Extensive Services

Rehabilitation 500 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week
Tracheostomy care
Ventilator or respirator
Isolation for active infectious disease while a resident
Activities of Daily Living (ADL) score of 2 or more

ADL Index Range: 2-10	0.2%
Total Percent:	0.2%

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week
A second rehabilitation discipline three days/week

ADL Index Range: 11-16	23.1%
ADL Index Range: 6-10	36.4%
ADL Index Range: 0-5	9.9%
Total Percent:	69.5%

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week

ADL Index Range: 11-16	5.3%
ADL Index Range: 6-10	4.7%
ADL Index Range: 0-5	1.4%
Total Percent:	11.4%

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week

ADL Index Range: 11-16	1.3%
ADL Index Range: 6-10	3.1%
ADL Index Range: 0-5	4.7%
Total Percent:	9.1%

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum

Five days any combination of three rehabilitation disciplines

ADL Index Range: 6-10	5.8%
ADL Index Range: 0-5	1.2%
Total Percent:	7.0%

Special Care Low

Cerebral palsy, multiple sclerosis, or Parkinson's disease with ADL score greater or equal to 5
Respiratory failure and oxygen therapy while a resident
Feeding tube where calories >= 51% or calories are in the range of 26-50% and fluid >= 501 mL)
Ulcers: 2 or more stage II or 1 or more stage III or IV pressure ulcers
Ulcers: 2 or more venous or arterial ulcers
Ulcers: 1 stage II pressure ulcer and 1 venous or arterial ulcer with 2 or more skin care treatments
Foot infection/diabetic foot ulcer/open lesions of foot with treatment
Radiation therapy while a resident
Dialysis while a resident
Activities of Daily Living (ADL) score of 2 or more

ADL Index Range: 11-14 - Signs of depression	0.7%
Total Percent:	0.7%

Behavioral Symptoms and Cognitive Performance

Cognitive impairment BIMS score less than or equal to 9
CPS great than or equal to 3
Hallucinations or delusions
Physical or verbal behavioral symptoms toward others
Other behavioral symptoms
Rejection of care or wandering
Activities of Daily Living (ADL) score of 5 or less

ADL Index Range: 2-5 - Less restorative nursing	1.7%
Total Percent:	1.7%

Reduced Physical Function

Urinary and/or bowel training program
Passive and/or active range of motion (ROM)
Amputation/prosthesis training
Dressing or grooming training
Eating or swallowing training
Transfer training
Splint or brace assistance
Bed mobility and/or walking training
Communication training

ADL Index Range: 6-10 - Less restorative nursing	0.5%
Total Percent:	0.5%

Rating Details For Elms Haven Care and Rehabilitation Center

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per Day	Reported	Expected
Registered Nurse (RN) Hours	28 Minutes	1 Hour and 5 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours	1 Hour and 2 Minutes	41 Minutes
Certified Nursing Assistant (CNA) Hours	1 Hour and 55 Minutes	2 Hours and 22 Minutes
Total Licensed Nurse Hours	1 Hour and 30 Minutes	1 Hour and 45 Minutes
Total Nurse Hours	3 Hours and 25 Minutes	4 Hours and 8 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Colorado are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This Facility

Colorado Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	73%	87%
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season	79%	88%

Long-Term Stay Deficiencies

Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores	3%	3%
Percent of Long-Stay Residents Who Lose Too Much Weight	10%	8%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain	3%	4%
Percent of Long-Stay Residents Who Were Physically Restrained	4%	4%
Percent of Long-Stay Residents Who Are More Depressed or Anxious	17%	16%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse	6%	11%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection	6%	9%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores	10%	9%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder	65%	48%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder	6%	7%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased	11%	15%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair	-	3%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season	50%	81%
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	26%	79%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Had Moderate to Severe Pain	31%	23%
Percent of Short-Stay Residents Who Have Pressure Sores	8%	9%
Percent of Short-Stay Residents Who Have Delirium	-	3%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/22/2010.

Degree of Harm

- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health

Residents Affected

- Isolated
- Some Residents
- Many Residents

Deficiencies Found By Inspectors

Degree of Harm

Residents Affected

Administration

Keep Accurate and Appropriate Medical Records. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Give or Get Lab Tests to Meet the Needs of Residents. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Provide Needed Housekeeping and Maintenance. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Provide Needed Housekeeping and Maintenance. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Have Enough Outside Airflow. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Protect Residents from Mistreatment, Neglect, And/Or Theft of Personal Property. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Nutrition and Dietary

Make Sure That Residents Are Well Nourished. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Offer Other Nutritional Food to Each Resident Who Will Not Eat the Food Served. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Make Sure That Residents Are Well Nourished. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Provide Food in a Way That Meets a Resident's Needs. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Pharmacy Service

1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Properly Mark Drugs and Other Similar Products. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Quality Care

Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Make Sure That Each Residents' Abilities to Take Care of Themselves Does Not Lessen, Unless a Change Cannot Be Avoided. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Give or Get Special Rehabilitation if in the Patient's Plan of Care. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Resident Assessment

Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Develop a Plan with the Resident and Family for the Resident's Care After Leaving the Nursing Home. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Screen Residents when They Are First Admitted to Send Them to an Area with Special Care for People with Developmental Disabilities or Mental Illness, if Needed. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Make Sure That Doctors See a Resident's Plan of Care at Every Visit and Make Notes About Progress and Orders in Writing. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Make Sure That Doctors Visit Residents Regularly, As Required. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Resident Rights

Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 10/03/2007 Correction Date: 11/15/2007
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 12/17/2008 Correction Date: 01/16/2009
Let the Resident Refuse Treatment or Refuse to Take Part in an Experiment. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Properly Hold, Secure and Manage Each Resident's Personal Money Which is Deposited with the Nursing Home. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Let Residents Give Themselves Their Drugs if They Are Able. Inspection Date: 03/22/2010 Correction Date: 04/11/2010
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 03/22/2010 Correction Date: 04/11/2010

Enforcement

Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.

Action Taken	Date	Amount
Civil Money Penalty (CMP)	03/22/2010	$975
Civil Money Penalty (CMP)	08/30/2010	$4,225
Civil Money Penalty (CMP)	03/22/2010	$4,550

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for Elms Haven Care and Rehabilitation Center, as well as complaints by residents or their family in the previous three years.

Degree of Harm

- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health

Residents Affected

- Isolated
- Some Residents
- Many Residents

Formal Complaints

Degree of Harm

Residents Affected