Federal inspection record · CMS data as of October 1, 2026
Columbine West Health And Rehab LLC
940 Worthington Cir, Fort Collins, CO · (970) 221-2273
- Certified beds
- 100
- Residents per day
- 90
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 20, 1988
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Colorado homes
Columbine West Health And Rehab LLC carries 49.75 inspection points. That is fewer than 60% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
16 health citations on record since 2019. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Quality of Life and Care3D
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Pharmacy Service2E
- E
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.
- D
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.
Infection Control2E
- D
Implement a program that monitors antibiotic use.
- E
Provide and implement an infection prevention and control program.
Resident Rights2E
- E
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.
- E
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.
Nutrition and Dietary2F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration1F
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Resident Assessment and Care Planning1D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspection history
2026-06-16
2 health deficiencies · 5 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2024-04-11
11 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2019-12-19
3 health deficiencies · 0 fire-safety deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 3 h 41 min of nursing staff time a day, 48 min of it from a registered nurse.
This home
3 h 41 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 56% of nursing staff and 54% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$26,891 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-02-27 | Fine | $16,653 |
| 2024-04-11 | Fine | $10,238 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts better | 1.1 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts better | 1.1 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine6.3 pts better | 99.7% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4 pts better | 97.7% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.6 pts better | 1.8% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.8 pts worse | 10.6% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.2 pts better | 1.6% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1.8 pts worse | 13.4% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication8.3 pts better | 11.6% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened6.6 pts worse | 18.3% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.8 pts worse | 20.6% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.1 pts worse | 0.6% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.6% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.2 pts worse | 29.8% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.1 pts better | 0.3% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine14.1 pts better | 91.1% | 77.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2.9 pts better | 9.1% | 12.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.6 pts worse | 3.2% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine11.3 pts better | 84.9% | 73.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission9.5 pts worse | 30.0% | 20.5% | 23.4% |
·
Fire safety
7 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Egress2E
- E
Have exits that are accessible at all times.
- D
Have exits that are accessible at all times.
Miscellaneous1F
- F
Have simulated fire drills held at unexpected times.
·
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