All citations for Columbine West Health and Rehab LLC
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
June 16, 2026
Showing 1 to 23 of 23 citations
Immediate jeopardy to resident health or safety
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
The home gave a date the problem would be corrected (March 21, 2025).
Harm to a resident
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
The home has a plan to correct it (October 1, 2026).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home has a plan to correct it (October 1, 2026).
No harm, with potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
The home gave a date the problem would be corrected (March 7, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
The home gave a date the problem would be corrected (May 16, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (January 13, 2020).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (June 17, 2026).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
The home has a plan to correct it (October 1, 2026).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
The home has a plan to correct it (October 1, 2026).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
The home has a plan to correct it (October 1, 2026).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (August 25, 2024).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Implement a program that monitors antibiotic use.
The home gave a date the problem would be corrected (June 29, 2026).
No harm, with potential for more than minimal harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
The home gave a date the problem would be corrected (March 19, 2025).
No harm, with potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (May 3, 2024).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
The home gave a date the problem would be corrected (May 21, 2024).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
The home gave a date the problem would be corrected (February 5, 2020).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.