Cycle 1
Health 2025-04-17 · Fire 2025-04-17
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Windsor, CO
Columbine Commons Health And Rehab LLC
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
1475 Main St, Windsor, CO
(970) 449-5540
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Columbine Health Systems
Operator or chain grouping
Approved since
2014-02-13
CMS approved date
Coverage
Medicare
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
1.44
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.42
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.52
CMS adjusted RN staffing hours
Adjusted total hours
4.72
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
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
476
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.38% · Performance 16.37% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.44
Baseline 4.80% · Performance 6.21% · Measure score 5.44 · Achievement 5.44 · Improvement 0
Total nurse turnover
6.33
Performance 37.80% · Measure score 6.33 · Achievement 6.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.90
Baseline 4.54 hours · Performance 4.76 hours · Measure score 5.90 · Achievement 5.90 · Improvement 1.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 234 · Observed rate 6.84% · Lower 95% interval 7.13% |
| Discharge to community | 68.83% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 228 · Observed rate 69.74% · Lower 95% interval 63.33% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 165 · Denominator 165 |
| Falls with major injury | 1.21% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 165 |
| Discharge self-care score | 69.35% |
53.69%
15.7 pts better
|
Numerator 86 · Denominator 124 |
| Discharge mobility score | 63.71% |
50.94%
12.8 pts better
|
Numerator 79 · Denominator 124 |
| Pressure ulcers or injuries, new or worsened | 2.42% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 165 · Adjusted rate 2.87% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 4.17% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 10.67% |
8.2%
2.5 pts better
|
Numerator 16 · Denominator 150 |
| Staff flu vaccination coverage | 94.88% |
42%
52.9 pts better
|
Numerator 204 · Denominator 215 |
| Discharge function score | 66.13% |
56.45%
9.7 pts better
|
Numerator 82 · Denominator 124 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | 98.98% |
96.28%
2.7 pts better
|
Numerator 97 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 56.25% |
25.2%
31.1 pts better
|
Numerator 45 · Denominator 80 |
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 1.5 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
93.5%
5.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.1% · 4Q avg 99.2% |
| 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 | 8.4% |
3.4%
5 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 9.4% · Q3 6.9% · Q4 5.7% · 4Q avg 8.4% · 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 2.9% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 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 0.0% · Q2 7.4% · Q3 0.0% · Q4 6.7% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
11.2%
2 pts worse
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 10.7% · Q3 4.3% · Q4 20.0% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
20.6%
2.1 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 27.3% · 4Q avg 22.7% · 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 | 32.9% |
15.2%
17.7 pts worse
|
16.3%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
14.6%
5.2 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 25.9% · Q3 28.6% · Q4 20.7% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.1% |
1.5%
6.6 pts worse
|
1.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 11.5% · Q4 14.3% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
22.4%
3.5 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 26.0% · Q3 24.0% · Q4 28.0% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
3.7%
3.5 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 7.2% · Q3 5.0% · Q4 4.3% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
76.4%
21 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.4% · Q3 97.6% · Q4 93.2% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.1% |
12.8%
5.3 pts worse
|
12.0%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 16.2% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.5%
1.9 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.7% · Q3 3.5% · Q4 5.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
75.6%
23.2 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
20.3%
7.9 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 27.6% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
4 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-07-14 · Fire 2022-07-14
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-23
F · Potential for more than minimal harm
2025-04-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-17
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-17
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 2025-07-01
D · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-01
D · Potential for more than minimal harm
2023-10-12
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-11-06
F · Potential for more than minimal harm
2022-07-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-04
F · Potential for more than minimal harm
2022-07-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-09-04
F · Potential for more than minimal harm
2022-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-04
F · Potential for more than minimal harm
2022-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-04
F · Potential for more than minimal harm
2022-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-04
F · Potential for more than minimal harm
2022-07-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-04
F · Potential for more than minimal harm
2022-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-04
E · Potential for more than minimal harm
2022-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-07-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-07-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-09-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-09
E · Potential for more than minimal harm
2023-10-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-12
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-25
D · Potential for more than minimal harm
2022-07-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-31
Penalties and ownership
What sits behind the stars
Ownership
Wilson, John
5% Or Greater Direct Ownership Interest · Individual
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
W-2 Managing Employee · Individual
Withrow, Palmer
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Pelican Pointe Health And Rehabilitation Center
Windsor, CO
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $42,860 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Lemay Avenue Health And Rehab LLC
Fort Collins, CO
5-star overall rating with 5-star inspections with $7,443 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society -- Fort Collins Village
Fort Collins, CO
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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