North Shore Health and Rehab Facility: Data Analysis and Ratings
CMS Five Star Rating(4 out of 5):
1365 W 29TH ST LOVELAND, CO 80538
970-667-6111
Data date: April 01, 2023
The Most Important Data about North Shore Health and Rehab Facility
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at North Shore Health and Rehab Facility. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(4 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Worsening
Total Nursing Hours Spent Per Resident Per Day: 4.17
(The national average is 3.74 )
According to our analysis, North Shore Health and Rehab Facility is ranked #14 out of 27 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near North Shore Health and Rehab Facility.
What is this page all about?
Below is everything shred of information that we can find about North Shore Health and Rehab Facility, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: April 01, 2023
Address: 1365 W 29TH ST
LOVELAND, CO 80538
Phone: 970-667-6111
Ranking: North Shore Health and Rehab Facility is ranked #7 out of 12 facilities within a 10 mile radius and #14 out of 27 facilities within a 25 mile radius.
Medicare Provider Number: 065129
Participating in Medicare Since: July 01, 1975
No. of Certified Beds: 125
No. of Residents: 89
Occupancy: 71.20 % (as of 05/21/2023 )
Amount fined in recent period: $23,407.80
Complaints filed: 1
Ratings History for North Shore Health and Rehab Facility
Review of North Shore Health and Rehab Facility Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 4: |
| Health Inspection Rating | 3: |
| Quality Rating | 4: |
| Staffing Rating | 5: |
Inspection Scores
| Cycle 1 Score (as of March 10, 2020) | 52 |
| Cycle 2 Score (as of March 05, 2019) | 48 |
| Cycle 3 Score (as of October 12, 2017) | 56 |
| Weighted All Cycles Score | 51 |
It has been 36 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for North Shore Health and Rehab Facility including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | September 11, 2020 |
| Fire Safety Standard | March 26, 2019 |
| Fire Safety Standard | November 08, 2017 |
| Health Complaint | July 26, 2022 |
| Health Standard | March 10, 2020 |
| Health Standard | March 05, 2019 |
| Health Standard | October 12, 2017 |
| Infection Control | March 02, 2022 |
| Infection Control | December 29, 2020 |
| Infection Control | August 19, 2020 |
Owner and Operator Information for North Shore Health and Rehab Facility
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Managers and Directors:
- COLUMBINE MANAGEMENT SERVICES INC (OPERATIONAL/MANAGERIAL CONTROL)
- BARRY FANCHER (OFFICER)
- BARRY FANCHER (MANAGING EMPLOYEE)
- LAUREN FASCIANO-SAGER (OFFICER)
- LAUREN FASCIANO-SAGER (MANAGING EMPLOYEE)
- JOHN WILSON (DIRECTOR)
- JOHN WILSON (MANAGING EMPLOYEE)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of North Shore Health and Rehab Facility spends MORE time on average with its residents than the state average for total nursing homes spent per resident and MORE time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 1.12 | 0.83 / 0.65 |
| Case Mix | 0.36 | 0.36 / 0.39 |
| Adjusted | 1.21 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 0.80 | 0.69 / 0.88 |
| Case Mix | 0.69 | NA / NA |
| Adjusted | 0.86 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 2.25 | 2.15 / 2.21 |
| Case Mix | 1.92 | NA / NA |
| Adjusted | 2.39 | NA / NA |
| Total Licensed Staff | ||
| Hours | 1.92 | 1.53 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.07 | 0.08 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 4.17 | 3.68 / 3.74 |
| Case Mix | 2.97 | 3.03 / 3.16 |
| Adjusted | 4.44 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison |
|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 19.6% |
19.4% Worse |
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 15.0% |
12.6% Worse |
| Number of hospitalizations per 1000 long-stay resident days (qm551) | 2.1% |
1.3% Worse |
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | 1.4% |
1.0% Worse |
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 9.8% |
15.3% Better |
| Percentage of long-stay residents who lose too much weight (qm404) | 4.3% |
6.2% Better |
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | 51.8% |
47.6% Worse |
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 0.0% |
2.0% Better |
| Percentage of long-stay residents with a urinary tract infection (qm407) | 5.5% |
2.0% Worse |
| Percentage of long-stay residents who have depressive symptoms (qm408) | 1.9% |
3.8% Better |
| Percentage of long-stay residents who were physically restrained (qm409) | 0.0% |
0.1% Better |
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 1.1% |
3.7% Better |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 98.9% |
86.9% Better |
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 11.8% |
17.7% Better |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 97.3% |
70.7% Better |
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 1.5% |
1.8% Better |
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | 16.8% |
15.8% Worse |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 5.5% |
12.3% Better |
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | 7.9% |
5.8% Worse |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | 100.0% |
93.6% Better |
| Percentage of short-stay residents who made improvements in function (qm471) | 83.5% |
75.7% Better |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | 93.6% |
68.8% Better |
North Shore Health and Rehab Facility Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $23,407.80, Complaints filed: 1
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Allow residents the right to participate in the planning or revision of care and treatment. (Health) | 10-12-2017 / 11-12-2017 |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. (Health) | 10-12-2017 / 12-15-2017 |
| Store, cook, and serve food in a safe and clean way. (Health) | 10-12-2017 / 12-03-2017 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. (Fire Safety) | 11-08-2017 / 12-18-2017 |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. (Fire Safety) | 11-08-2017 / 12-18-2017 |
| Install an approved automatic sprinkler system. (Fire Safety) | 11-08-2017 / 12-18-2017 |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. (Fire Safety) | 11-08-2017 / 11-28-2017 |
| Have restrictions on the use of highly flammable decorations. (Fire Safety) | 11-08-2017 / 12-18-2017 |
| Reasonably accommodate the needs and preferences of each resident. (Health) | 03-05-2019 / 04-12-2019 |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Health) | 03-05-2019 / 04-12-2019 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Health) | 03-05-2019 / 04-05-2019 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (Health) | 03-05-2019 / 04-17-2019 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 03-05-2019 / 04-17-2019 |
| Provide and implement an infection prevention and control program. (Health) | 03-05-2019 / 04-10-2019 |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. (Fire Safety) | 03-26-2019 / 03-28-2019 |
| Provide properly protected cooking facilities. (Fire Safety) | 03-26-2019 / 04-01-2019 |
| Inspect, test, and maintain automatic sprinkler systems. (Fire Safety) | 03-26-2019 / 04-01-2019 |
| Properly select, install, inspect, or maintain portable fire extinguishes. (Fire Safety) | 03-26-2019 / 04-19-2019 |
| Install corridor and hallway doors that block smoke. (Fire Safety) | 03-26-2019 / 04-01-2019 |
| Have restrictions on the use of highly flammable decorations. (Fire Safety) | 03-26-2019 / 04-22-2019 |
| Honor the resident's right to manage his or her financial affairs. (Health) | 03-10-2020 / 04-24-2020 |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. (Health) | 03-10-2020 / 04-24-2020 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Health) | 03-10-2020 / 04-30-2020 |
| Provide activities to meet all resident's needs. (Health) | 03-10-2020 / 04-17-2020 |
| 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. (Health) | 03-10-2020 / 04-30-2020 |
| Provide and implement an infection prevention and control program. (Health) | 03-10-2020 / 04-24-2020 |
| Establish emergency prep training and testing. (Fire Safety) | 03-10-2020 / 04-24-2020 |
| Establish staff and initial training requirements. (Fire Safety) | 03-10-2020 / 04-24-2020 |
| Provide and implement an infection prevention and control program. (Health) | 08-19-2020 / 09-17-2020 |
| Use approved construction type or materials. (Fire Safety) | 09-11-2020 / 09-25-2020 |
| 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. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Install emergency lighting that can last at least 1 1/2 hours. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Have properly located and lighted "Exit" signs. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. (Fire Safety) | 09-11-2020 / 10-28-2020 |
| Provide properly protected cooking facilities. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Install a fire alarm system that can be heard throughout the facility. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Have approved installation, maintenance and testing program for fire alarm systems. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Install an approved automatic sprinkler system. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Inspect, test, and maintain automatic sprinkler systems. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Have properly installed electrical wiring and gas equipment. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Provide a written emergency evacuation plan. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Have simulated fire drills held at unexpected times. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Meet requirements for the installation and maintenance of electrical systems. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Have generator or other power source capable of supplying service within 10 seconds. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Ensure proper usage of power strips and extension cords. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Have proper medical gas storage and administration areas. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. (Fire Safety) | 09-11-2020 / 10-24-2020 |
| Provide and implement an infection prevention and control program. (Health) | 12-29-2020 / 02-01-2021 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Health) | 07-26-2022 / 08-23-2022 |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. (Health) | 07-26-2022 / 08-10-2022 |
Hospitals Near North Shore Health and Rehab Facility
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near North Shore Health and Rehab Facility.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
NORTH COLORADO MEDICAL CENTER 1801 16TH ST GREELEY, CO 80631 |
2 |
|
CENTURA LONGMONT UNITED HOSPITAL 1950 MOUNTAIN VIEW AVE LONGMONT, CO 80501 |
3 |
|
MCKEE MEDICAL CENTER 2000 BOISE AVE LOVELAND, CO 80538 |
4 |
|
POUDRE VALLEY HOSPITAL 1024 S LEMAY AVE FORT COLLINS, CO 80524 |
5 |
|
MEDICAL CENTER OF THE ROCKIES 2500 ROCKY MOUNTAIN AVE LOVELAND, CO 80538 |
5 |
|
LONGS PEAK HOSPITAL 1750 E KEN PRATT BLVD LONGMONT, CO 80504 |
5 |
|
BANNER FORT COLLINS MEDICAL CENTER 4700 LADY MOON DR FORT COLLINS, CO 80528 |
Not Available |
|
UCHEALTH GREELEY HOSPITAL 6767 W 29TH ST GREELEY, CO 80634 |
Not Available |
|
ESTES PARK MEDICAL CENTER 555 PROSPECT AVE ESTES PARK, CO 80517 |
Not Available |
|
JOHNSTOWN HEIGHTS BEHAVIORAL HEALTH LLC 4770 LARIMER PKWY JOHNSTOWN, CO 80534 |
Not Available |
Medical Professionals Associated with North Shore Health and Rehab Facility
These are the doctors who are affiliated with North Shore Health and Rehab Facility. The data is from the most recent period. Historical data is not available.
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for North Shore Health and Rehab Facility
Five different rating results plus detailed inspection numbers and quality measures for North Shore Health and Rehab Facility.
Covid Infections at North Shore Health and Rehab Facility
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for North Shore Health and Rehab Facility
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for North Shore Health and Rehab Facility
A list of all of the registered owners for North Shore Health and Rehab Facility. This includes direct and indirect owners and managers.
Noted Deficiencies for North Shore Health and Rehab Facility
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does North Shore Health and Rehab Facility compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in LOVELAND, CO
Homes that you should consider. A list ranking the best skilled nursing facilities in LOVELAND based on their weighted inspection score as of April 01, 2023.
Worst Nursing Homes in LOVELAND, CO
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in LOVELAND based on their weighted inspection score as of April 01, 2023.
Other Data Periods:
Data on North Shore Health and Rehab Facility is available for the following periods:
