Columbine Commons Health and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Columbine Commons Health and Rehab LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 17, 2025

  Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two out of two kitchenettes. Specifically, the facility failed to ensure: -Refrigerators were maintained at the correct temperature; -Food was properly stored after being opened; -Staff wore beard nets in the kitchen; -Staff did not have fake nails; and, -Staff did not wear a watch on their wrist while serving food. Findings include: I. Failure to ensure refrigerator temperatures were maintained appropriately A. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. […]

• No harm, potential for more than minimal, patternF880Oct 12, 2023

  Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure glucometers were disinfected per manufacturer's recommendations and ensure that individual glucometers were labeled on three of four medication carts reviewed; -Follow infection control practices when administering medications via gastrostomy (G-tube) tube; and, -Follow infection control practices when entering the room of a resident on contact precautions. Findings include: I. Standard precautions for resident equipment-disinfection and labeling of glucometers A. […]

• No harm, potential for more than minimal, isolatedF677Apr 17, 2025

  Based on record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain grooming and personal hygiene for one (#8) of four residents reviewed out of 17 sample residents. Specifically, the facility failed to provide Resident #8 with timely bathroom assistance. Findings include: I. Facility policy and procedure The Resident Rights policy, revised on 2/26/25, was provided by the nursing home administrator (NHA) on 4/18/25 at 4:14 p.m. […]

• No harm, potential for more than minimal, isolatedF678Oct 12, 2023

  Based on record review and interviews, the facility failed to have a process in place to ensure one (#48) resident reviewed for cardiopulmonary resuscitation (CPR) out of 28 sample residents choices regarding CPR were honored and physician orders in place to support the choices. Specifically, the facility failed to ensure the physician orders were updated after admission to do not resuscitate (DNR) status in order to align with the Resident #48's documented choices. Findings include: I. Facility policy The Advance Directives and Resident Contacts policy, revised [DATE], was provided by the director of clinical services (DCS) on [DATE] at 10:45 p.m. […]

• No harm, potential for more than minimal, isolatedF761Oct 12, 2023

  Based on observations, record review and interviews, the facility failed to ensure proper storage and disposal of medications in two of three medication carts. Specifically, the facility failed to discard prepared and contaminated medications that had not been administered to residents. Findings include: I. Facility policy and procedure The Medication Receiving, Storage, and Destruction policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE]. It read in pertinent part, Expired, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. II. Observations On [DATE] at 12:23 p.m. […]