Cycle 1
Health 2024-10-03 · Fire 2024-10-03
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fort Collins, CO
Centre Ave Health And Rehabilitation LLC
5-star overall rating with 5-star inspections with $8,044 in total fines with 7 fire-safety deficiencies in the latest cycle
815 Centre Ave, Fort Collins, CO
(970) 494-2140
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Columbine Health Systems
Operator or chain grouping
Approved since
2001-10-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.58
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.43
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.98
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.66
CMS adjusted RN staffing hours
Adjusted total hours
4.67
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
885
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0174
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.03% · Performance 16.02% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 4.80% · Performance 4.98% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
0.58
Baseline 54.78% · Performance 61.29% · Measure score 0.58 · Achievement 0.58 · Improvement 0
Adjusted total nurse staffing
4.41
Baseline 3.87 hours · Performance 4.33 hours · Measure score 4.41 · Achievement 4.41 · Improvement 1.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 421 · Observed rate 8.31% · Lower 95% interval 7.55% |
| Discharge to community | 71.93% |
50.57%
21.4 pts better
|
Better than the National Rate · Eligible stays 373 · Observed rate 71.31% · Lower 95% interval 67.74% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 225 · Denominator 228 |
| Falls with major injury | 1.32% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 228 |
| Discharge self-care score | 59.69% |
53.69%
6 pts better
|
Numerator 117 · Denominator 196 |
| Discharge mobility score | 56.63% |
50.94%
5.7 pts better
|
Numerator 111 · Denominator 196 |
| Pressure ulcers or injuries, new or worsened | 3.96% |
2.29%
1.7 pts worse
|
Numerator 9 · Denominator 227 · Adjusted rate 5.33% |
| Healthcare-associated infections requiring hospitalization | 4.98% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 235 · Observed rate 2.55% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 23.35% |
8.2%
15.2 pts better
|
Numerator 46 · Denominator 197 |
| Staff flu vaccination coverage | 95% |
42%
53 pts better
|
Numerator 304 · Denominator 320 |
| Discharge function score | 57.65% |
56.45%
1.2 pts better
|
Numerator 113 · Denominator 196 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 179 · Denominator 179 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 58.16% |
25.2%
33 pts better
|
Numerator 57 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.4%
2.4 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
7.4%
5.8 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.1% · Q4 2.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.0%
0.9 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.3% · Q3 6.1% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
11.2%
8 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 18.4% · Q3 21.2% · Q4 21.6% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
20.6%
13.6 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 10.0% · Q3 6.1% · Q4 6.2% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.7% |
15.2%
5.5 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
14.6%
8 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 5.6% · Q3 9.7% · Q4 0.0% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.5%
1 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 4.2% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
22.4%
5 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 21.0% · Q3 25.3% · Q4 12.1% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
3.7%
1.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.6% · Q3 6.4% · Q4 6.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
76.4%
21.9 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 99.2% · Q3 98.1% · Q4 98.6% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
12.8%
0.6 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 11.9% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
75.6%
19.7 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
20.3%
3.7 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 14.0% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-18 · Fire 2023-04-18
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-02-09 · Fire 2022-02-09
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-10-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-05
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-06
E · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-04-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-03
F · Potential for more than minimal harm
2023-04-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-04-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-19
F · Potential for more than minimal harm
2022-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-29
F · Potential for more than minimal harm
2022-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-02-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-06
D · Potential for more than minimal harm
2022-02-09
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-03-06
Inspection history
Recent health citations
G · Actual harm
2023-04-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-04-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-27
G · Actual harm
2022-02-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-02-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-03-11
Penalties and ownership
What sits behind the stars
$8,044
2023-04-18
Fine
Fine · fine $8,044
Fine
Ownership
Wilson, John
5% Or Greater Direct Ownership Interest · Individual
Columbine Management Services Inc
Operational/Managerial Control · Organization
Fancher, Barry
Corporate Officer · Individual
Fancher, Barry
W-2 Managing Employee · Individual
Fasciano-Sager, Lauren
Corporate Officer · Individual
Fasciano-Sager, Lauren
W-2 Managing Employee · Individual
Wilson, John
Corporate Director · Individual
Wilson, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Columbine West Health And Rehab LLC
Fort Collins, CO
3-star overall rating with 2-star inspections with abuse icon flag with $26,891 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Creekside Village Rehabilitation And Nursing LLC
Fort Collins, CO
1-star overall rating with 1-star inspections with abuse icon flag with $28,042 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Poudre Canyon Rehabilitation And Nursing, LLC
Fort Collins, CO
2-star overall rating with 1-star inspections with abuse icon flag with $45,688 in total fines with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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