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
Staffing
Hours and turnover
RN hours / resident day
1.58
Registered nurse staffing
LPN hours / resident day
0.41
Licensed practical nurse staffing
Aide hours / resident day
2.44
Nurse aide staffing
Weekend hours
3.80
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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