Cycle 1
Health 2024-04-11 · Fire 2024-04-11
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fort Collins, CO
Columbine West Health And Rehab LLC
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
940 Worthington Cir, Fort Collins, CO
(970) 221-2273
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Columbine Health Systems
Operator or chain grouping
Approved since
1988-12-20
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
1.08
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.23
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,306
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.74
Composite VBP score used to determine payment impact.
Payment multiplier
1.0129
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.15
Baseline 19.50% · Performance 18.12% · Measure score 7.15 · Achievement 7.15 · Improvement 5.09
Healthcare-associated infections
5.95
Baseline 5.72% · Performance 6.06% · Measure score 5.95 · Achievement 5.95 · Improvement 0
Total nurse turnover
3.57
Performance 49.11% · Measure score 3.57 · Achievement 3.57 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.43
Baseline 4.28 hours · Performance 4.91 hours · Measure score 6.43 · Achievement 6.43 · Improvement 3.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 6.33% · Lower 95% interval 6.62% |
| Discharge to community | 59.17% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 59.38% · Lower 95% interval 50.15% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 91.18% |
95.27%
4.1 pts worse
|
Numerator 31 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 40.63% |
53.69%
13.1 pts worse
|
Numerator 13 · Denominator 32 |
| Discharge mobility score | 40.63% |
50.94%
10.3 pts worse
|
Numerator 13 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 0% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 27.67% |
8.2%
19.5 pts better
|
Numerator 44 · Denominator 159 |
| Staff flu vaccination coverage | 99.23% |
42%
57.2 pts better
|
Numerator 259 · Denominator 261 |
| Discharge function score | 46.88% |
56.45%
9.6 pts worse
|
Numerator 15 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 11 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.2 · 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 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
93.5%
2.3 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 95.4% · Q3 100.0% · Q4 100.0% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.7%
4.2 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.4%
3.1 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
7.4%
5.2 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 0.0% · Q4 1.2% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.0%
1.6 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.8% · Q3 3.2% · Q4 1.6% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
11.2%
3.1 pts worse
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.1% · Q3 15.9% · Q4 14.3% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
20.6%
8.4 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 18.6% · Q3 10.9% · Q4 7.3% · 4Q avg 12.2% · 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 | 20.0% |
15.2%
4.8 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 15.6% · Q3 20.9% · Q4 20.9% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
14.6%
0.8 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 8.6% · Q3 21.0% · Q4 13.1% · 4Q avg 13.8% · 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 | 1.8% |
1.5%
0.3 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
22.4%
5.1 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 31.4% · Q3 21.2% · Q4 30.5% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
3.7%
3 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.2% |
76.4%
10.8 pts better
|
81.7%
5.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.2% · Q2 88.6% · Q3 86.8% · Q4 91.1% · 4Q avg 87.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
12.8%
8.5 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 3.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3% |
75.6%
4.7 pts better
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
20.3%
1.7 pts worse
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 19.2% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-19 · Fire 2019-12-19
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-11-01 · Fire 2018-11-01
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-21
D · Potential for more than minimal harm
2018-11-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-12-27
Inspection history
Recent health citations
J · Immediate jeopardy
2025-02-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-02-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-27
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-03-19
E · Potential for more than minimal harm
2024-08-06
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-08-25
G · Actual harm
2024-04-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-11
F575 · Resident Rights Deficiencies
Health
Post 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.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-11
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 2024-05-03
E · Potential for more than minimal harm
2024-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-05-03
F · Potential for more than minimal harm
2019-12-19
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 2020-01-13
D · Potential for more than minimal harm
2019-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-05
F · Potential for more than minimal harm
2018-11-01
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 2019-01-09
D · Potential for more than minimal harm
2018-11-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-12-05
D · Potential for more than minimal harm
2018-11-01
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 2018-12-07
Penalties and ownership
What sits behind the stars
$16,653
2025-02-27
Fine
Fine · fine $16,653
Fine
$10,238
2024-04-11
Fine
Fine · fine $10,238
Fine
Ownership
Columbine Management Services Inc
Operational/Managerial Control · Organization
Fancher, Barry
Corporate Director · Individual
Fancher, Barry
W-2 Managing Employee · Individual
Fasciano-Sager, Lauren
Corporate Officer · Individual
Fasciano-Sager, Lauren
W-2 Managing Employee · Individual
Wilson, John
5% Or Greater Direct Ownership Interest · Individual
Wilson, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Centre Ave Health And Rehabilitation LLC
Fort Collins, CO
5-star overall rating with 5-star inspections with $8,044 in total fines with 7 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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