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COLUMBINE WEST HEALTH AND REHAB LLC Inspection Report, Violations & Safety Grade (FORT COLLINS, Colorado)

940 WORTHINGTON CIR, FORT COLLINS, Colorado 80526

Phone: 9702212273

CMS Overall:3/5

Overview & Bed Count

Certified Beds
100
Avg Residents/Day
90.3
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Larimer
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health3/5
Staffing3/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityColorado AvgDifference
RN Hours per Resident per Day0.810.81-0.01
Total Nurse Hours per Resident per Day3.683.69-0.02
CMS Staffing Rating3/53.1/5-
Nursing Staff Turnover56.4%47%-

Health Citation History

16 health citations on record

DateCategoryDescriptionSeverity
2026-06-16Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2026-06-16Infection Control DeficienciesImplement a program that monitors antibiotic use.D – Moderate Harm Potential
2025-02-27Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.J – Immediate Jeopardy
2025-02-27Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.F – Moderate Harm Potential
2025-02-27Quality of Life and Care DeficienciesProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.D – Moderate Harm Potential
2024-08-06Resident Rights DeficienciesHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.E – Moderate Harm Potential
2024-04-11Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.G – Actual Harm
2024-04-11Resident Rights DeficienciesPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.E – Moderate Harm Potential
2024-04-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2024-04-11Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2024-04-11Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2024-04-11Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-04-11Quality of Life and Care DeficienciesProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.D – Moderate Harm Potential
2024-04-11Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2019-12-19Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2019-12-19Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential

Fire Safety Citation History

7 fire safety citations on record

DateCategoryDescriptionSeverity
2026-06-16Smoke DeficienciesHave a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.F – Moderate Harm Potential
2026-06-16Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2026-06-16Egress DeficienciesHave exits that are accessible at all times.E – Moderate Harm Potential
2026-06-16Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2026-06-16Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2024-04-11Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2024-04-11Egress DeficienciesHave exits that are accessible at all times.D – Moderate Harm Potential

Total Penalties & Fines

$26,891
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
DateTypeFine AmountPayment Denial
2025-02-27Fine$16,653-
2024-04-11Fine$10,238-

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