Columbine West Health And Rehab Llc faces challenges in its CMS ratings, earning a D grade with a score of 53/100. The facility ranks in the 48th percentile among Colorado nursing homes, suggesting significant room for improvement.
Staffing at Columbine West Health And Rehab Llc is near the national average, with 3.93 total nursing hours per resident per day (national average: 3.8 hours).
Recent CMS inspections identified 17 deficiencies at Columbine West Health And Rehab Llc, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.93 | 3.8 | Average |
| Registered Nurses (RN) | 1.08 | 0.7 | Above Average |
| Licensed Practical Nurses (LPN) | 0.48 | 0.7 | Below Average |
| Certified Nursing Assistants (CNA) | 2.37 | 2.4 | Average |
| Weekend Total Nursing | 3.34 | 3.8 | Below Average |
| Weekend RN Hours | 0.79 | 0.7 | Above Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0600 Severity JProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Feb 26, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0867 Severity FSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Feb 26, 2025 · Administration Deficiencies
- Tag 0744 Severity DProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Feb 26, 2025 · Quality of Life and Care Deficiencies
- Tag 0584 Severity EHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for dAug 5, 2024 · Resident Rights Deficiencies
- Tag 0686 Severity GProvide appropriate pressure ulcer care and prevent new ulcers from developing.Apr 10, 2024 · Quality of Life and Care Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 0.7% | 4.5% | Better |
| Falls with major injury | 0.3% | 3.0% | Better |
| On antipsychotic medication | 12.2% | 14.5% | Better |
| Urinary tract infections | 1.8% | 2.5% | Better |
| ADL decline (daily activities) | 13.8% | 14.0% | Average |
| Excessive weight loss | 3.4% | 7.5% | Better |
| New/worsened incontinence | 27.5% | 45.0% | Better |
⚠️ Penalties & Fines
2 penalties recorded by CMS
Total fines: $26,891
How This Grade Was Calculated
This facility's grade of D is based on a score of 53 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 3★ → 24 pts (max 40)
- Health Inspection Rating: 2★ → 10 pts (max 25)
- Staffing Rating: 4★ → 16 pts (max 20)
- Quality Measures Rating: 5★ → 15 pts (max 15)
- Penalty deductions: -10 pts
- Fine deductions: -2 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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