Deficiencies (last 5 years)
Deficiencies (over 5 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident sexual abuse incidents involving Residents #1, #2, #3, and #4 in the facility.
Complaint Details
The complaint investigation revealed incidents of sexual abuse by Resident #2 and Resident #4 toward female residents, including grabbing and rubbing breasts. The facility failed to adequately supervise, educate staff, update care plans, and monitor behaviors. Immediate jeopardy was identified due to these failures.
Findings
The facility failed to protect residents from resident-to-resident sexual abuse by Residents #2 and #4, failed to educate and inform staff about these behaviors, and did not implement or monitor appropriate interventions. This failure created an immediate jeopardy situation. Additionally, the facility failed to provide appropriate dementia care for Resident #1 and did not maintain an effective quality assurance program to identify and address compliance concerns.
Deficiencies (3)
Failure to protect residents from resident-to-resident sexual abuse, including inadequate staff education, monitoring, and intervention implementation.
Failure to provide appropriate treatment and services to a resident diagnosed with dementia to attain or maintain highest practicable well-being.
Failure to ensure an effective quality assurance program to identify and address facility compliance concerns.
Report Facts
Residents in secured unit: 14
Residents affected by abuse: 4
One-to-one supervision duration: 2
Number of one-on-one social visits for Resident #1 in January 2025: 2
Number of one-on-one social visits for Resident #1 in February 2025: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Assigned to provide one-to-one supervision for Resident #2 and monitored sexually inappropriate behaviors. |
| LPN #3 | Licensed Practical Nurse | Updated on monitoring sexual behaviors of Residents #2 and #4 and communication binder use. |
| CNA #5 | Certified Nurse Aide | Reported Resident #4's sexually inappropriate behaviors and care plan updates. |
| CNA #4 | Certified Nurse Aide | Educated on Resident #2's behaviors and communication binder. |
| RN #1 | Registered Nurse | Educated on Resident #4's behaviors and responsible for reviewing communication book. |
| CNA #2 | Certified Nurse Aide | Educated on Residents #2 and #4's behaviors and communication procedures. |
| DA #1 | Dietary Aide | Educated on redirecting Residents #2 and #4 and reporting inappropriate behaviors. |
| Director of Therapy | Director of Therapy | Educated entire therapy department on Residents #2 and #4's behaviors. |
| NHA | Nursing Home Administrator | Notified of immediate jeopardy and responsible for facility plan to remove it. |
| DON | Director of Nursing | Provided information on care plan expectations and monitoring for secured unit residents. |
| SSD | Social Services Director | Conducted interviews and assessments related to abuse incidents. |
| RN #2 | Registered Nurse | Floor nurse assigned to secured unit, involved in medication pass and monitoring. |
| CNA #3 | Certified Nurse Aide | Reported learning of behaviors through report and unaware of sexual incidents. |
| LPN #1 | Licensed Practical Nurse | Monitored residents for behaviors and received verbal shift reports. |
| LPN #2 | Licensed Practical Nurse | Relied on CNAs for communication and monitored Resident #2's expressions of need. |
| CNA #6 | Certified Nurse Aide | Reported Resident #1's wandering and interactions with other residents. |
| CNA #1 | Certified Nurse Aide | Described Resident #1's behaviors and responses to activities. |
| AAD | Assistant Activities Director | Provided information on activities and one-on-one visits for Resident #1. |
| CNA #8 | Certified Nurse Aide | Discussed plans to add activities to reduce behaviors on secured unit. |
Inspection Report
Routine
Capacity: 70
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment, specifically focusing on indoor climate control and resident room temperatures during the late spring and summer months.
Findings
The facility failed to ensure resident rooms had safe and comfortable temperatures, with multiple rooms observed at 84 to 90 degrees Fahrenheit, exceeding the facility's policy limit of 81 degrees. Residents, family members, and staff reported excessive heat causing discomfort, and the air conditioning system only cooled hallways, not individual rooms.
Deficiencies (1)
Failure to maintain resident room temperatures at or below 81 degrees Fahrenheit, resulting in rooms measuring up to 90 degrees.
Report Facts
Resident rooms: 70
Resident rooms sampled: 15
Resident rooms with temperature issues: 13
Temperature readings: 84
Temperature reading: 90
BIMS scores: 4
BIMS scores: 15
BIMS scores: 12
BIMS scores: 6
BIMS scores: 13
BIMS scores: 15
Thermostat settings: 72
Thermostat settings: 70
Air temperature: 79
Air temperature: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Reported observing temperatures about 81 degrees and residents/families complaining about heat |
| Licensed Practical Nurse #2 | LPN | Reported residents and families said it was too hot and made residents feel tired |
| Maintenance Supervisor | MS | Provided temperature logs, described air conditioning system and temperature monitoring |
| Nursing Home Administrator | NHA | Interviewed regarding temperature monitoring and resident complaints |
| Certified Nurse Aides #1, #2, #3, #4, #5 | CNA | Reported residents and families complained about excessive heat in the facility |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights postings, abuse prevention, care planning, pressure ulcer prevention, dementia care, psychotropic medication use, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to post complaint filing information accessibly, inadequate prevention and response to resident-to-resident sexual abuse, failure to revise care plans timely for pain medication refusals, development of a pressure injury due to delayed prevention measures, failure to provide person-centered dementia care, failure to monitor and justify psychotropic medication use, improper food holding temperatures and labeling, and inadequate infection control practices including PPE use and enhanced barrier precautions.
Deficiencies (10)
Failed to post complaint filing information in a manner accessible and understandable to residents.
Failed to protect residents from potential sexual abuse by another resident and failed to adequately assess, document, and revise care plans related to inappropriate sexual behaviors.
Failed to revise care plan timely to address repeated refusals of pain medications for Resident #56.
Failed to implement timely pressure injury prevention measures resulting in a facility-acquired deep tissue injury to Resident #30's right heel.
Failed to provide person-centered dementia care for Resident #43, including failure to address repetitive requests for food and lack of meaningful engagement.
Failed to track and monitor behaviors and side effects related to psychotropic medications for Resident #66, who was on multiple psychotropic drugs without documented rationale or behavior monitoring.
Failed to maintain appropriate holding temperatures for tartar sauce, which was found at 62°F instead of below 41°F.
Failed to label and date opened food items in refrigerators, including a chocolate milkshake dated 10 days prior, an opened almond milk carton without discard date, and nutritional supplements without thaw dates.
Failed to implement enhanced barrier precautions for residents with wounds or indwelling devices, including failure of staff to don gowns and gloves during high-contact care and wound dressing changes.
Failed to use appropriate PPE when entering the room of a COVID-19 positive resident, including failure to wear N95 mask properly and wearing surgical mask under N95.
Report Facts
Residents affected: 8
Residents affected: 15
Residents affected: 36
Residents affected: 4
Residents affected: 5
Residents affected: 5
Temperature: 62
Days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding complaint posting and sexual abuse incident |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding sexual abuse incident and training |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication refusals for Resident #56 |
| Nurse Manager #1 | Nurse Manager | Interviewed regarding medication refusals and dementia care |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication refusals and psychotropic medication monitoring |
| Certified Nurse Aide #5 | Certified Nurse Aide | Interviewed regarding Resident #43's sexual behaviors |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding Resident #43's sexual behaviors |
| Registered Nurse #5 | Registered Nurse | Interviewed regarding Resident #43's sexual behaviors |
| Registered Dietician | Registered Dietician | Interviewed regarding food safety and labeling |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and labeling |
| Infection Preventionist | Infection Preventionist | Interviewed regarding PPE and infection control |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding PPE use in COVID-19 positive room |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as an annual survey of Columbine West Health and Rehab LLC to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 19, 2019
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to provide appropriate treatment and care according to physician orders and professional standards, specifically regarding blood pressure medication administration and monitoring of bruising after a fall.
Complaint Details
The complaint investigation found substantiated issues with medication administration errors for Resident #18 and inadequate monitoring of bruising after a fall for Resident #82. The facility also had deficiencies in food safety and sanitation practices.
Findings
The facility failed to follow physician orders for blood pressure medication administration for Resident #18 and failed to monitor bruising for healing after a fall for Resident #82. Additionally, the facility failed to maintain sanitary food preparation and service practices, including preventing cross contamination and ensuring proper hand hygiene during meal delivery.
Deficiencies (3)
Failed to provide appropriate treatment and care according to physician orders for blood pressure medication for Resident #18.
Failed to monitor bruising for healing after a fall for Resident #82.
Failed to prepare, distribute, and serve food in a sanitary manner, including preventing cross contamination, ensuring drink stations were free of contamination, and using proper hand hygiene during meal delivery.
Report Facts
Residents reviewed: 6
Sample residents: 30
Blood pressure readings above 180 mmHg: 5
Residents affected: Few residents affected by medication and bruising deficiencies
Residents affected: Many residents affected by food safety deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered nurse #1 | Registered Nurse | Interviewed regarding blood pressure medication administration errors for Resident #18 |
| Corporate nurse consultant | Corporate Nurse Consultant | Interviewed regarding documentation errors and medication administration expectations |
| Director of nursing | Director of Nursing | Interviewed regarding medication administration orders and skin monitoring policies |
| Registered nurse #2 | Registered Nurse | Completed event report on Resident #82's fall and interviewed about bruise monitoring |
| Dietary manager | Dietary Manager | Interviewed regarding food safety and sanitation practices |
| Nursing home administrator | Nursing Home Administrator | Provided policies and interviewed regarding food safety and sanitation concerns |
| Job coach | Job Coach | Interviewed regarding supervision and training of community student volunteer |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 1, 2018
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain resident dignity related to religious activities, inadequate supervision to prevent falls, and improper food storage and temperature monitoring.
Complaint Details
The complaint investigation was triggered by concerns about resident rights violations related to religious activities, inadequate supervision leading to falls and injuries including a resident death, and food safety violations in the facility.
Findings
The facility failed to respect a resident's religious rights by not properly labeling a religious activity, failed to provide adequate supervision to prevent falls resulting in injury and death for multiple residents, and failed to maintain sanitary food storage and proper freezer temperature monitoring in unit kitchenettes.
Deficiencies (3)
Failed to keep Resident #53 free from unwanted religious activities by not listing on the activity calendar a specific recurring religious group leading a bible study.
Failed to ensure three residents (#70, #94, #91) remained free from falls and accident hazards and received adequate assistance devices to prevent accidents.
Failed to store, prepare, distribute and serve food under sanitary conditions, including lack of thermometers in unit freezers and improper food storage in unit kitchenettes.
Report Facts
Residents reviewed for dignity: 29
Residents reviewed for accidents: 29
Residents affected by dignity deficiency: 1
Residents affected by accident hazards deficiency: 3
Residents affected by food safety deficiency: Many
Resident #70 weight: 294
Resident #70 height: 72
Resident #94 BIMS score: 5
Resident #53 BIMS score: 15
Resident #70 BIMS score: 15
Resident #91 age: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Named in supervision failure related to Resident #94 fall | |
| CNA #5 | Named in falls involving Resident #70 | |
| Director of Nursing | DON | Provided policy and interview regarding fall prevention and supervision |
| Nursing Home Administrator | NHA | Interviewed regarding religious activity labeling and fall incidents |
| Occupational Therapist | OT | Provided assessments and interviews regarding Resident #70 and #94 transfers and supervision |
| Activity Director | AD | Interviewed regarding religious activity labeling |
| Activity Assistant | AA | Interviewed regarding religious activity labeling |
| Dietary Manager | DM | Interviewed regarding food storage and freezer temperature monitoring |
| Housekeeping Supervisor | HKS | Interviewed regarding cleaning and temperature monitoring responsibilities |
| Registered Nurse #1 | RN | Interviewed regarding food storage and ice pack handling |
| Certified Nurse Assistant #4 | CNA | Interviewed regarding sling sizes and Resident #70 care |
| Certified Nurse Assistant #6 | CNA | Named as CNA working with Resident #70 during fall |
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