Columbine West Health and Rehab LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 27, 2025

  Based on interviews and record review, the facility failed to protect and promote an environment free from resident-to-resident sexual abuse. The facility failure affected four of four residents (#1, #2, #3, and #4) out of seven sample residents and contributed to incidents of abuse by Resident #2 and #4. Residents #1 and #2 resided in the facility's secured unit. Fourteen residents resided in the secured unit: four male (including Resident #2) and 10 female (including Resident #1). Residents #3 and #4 resided in the non-secured unit. Resident #2 had a history of being verbally sexually inappropriate toward female residents and staff. On 2/5/25, staff observed Resident #2 grabbing the breast of female Resident #1 and lifting her shirt. When told to stop, Resident #2 stated, She likes it. […]

• Actual harm, isolatedF686Apr 11, 2024

  Based on observations, record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for pressure injuries out of 36 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Resident #30 was admitted on [DATE] for long term care. At the time of the admission, the resident was identified as being at risk for developing pressure injuries. Upon admission, the resident's skin was intact and she did not have any pressure injuries. Resident #30 attended dialysis three times a week. On 10/7/23, a nurse documented Resident #30 developed a deep tissue injury (DTI) on her right heel. Preventative measures to protect the resident's heels were not implemented until after the development of the DTI on 10/7/23. […]

• No harm, potential for more than minimal, widespreadF867Feb 27, 2025

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm. Findings include: I. […]

• No harm, potential for more than minimal, patternF761Jun 16, 2026

  Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication storage carts and two of two storage closets. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened;-Ensure expired medication were removed and discarded from the medication carts; and,-Ensure medications were stored in a secured area. Findings include: I. […]

• No harm, potential for more than minimal, patternF584Aug 6, 2024

  Based on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents who resided in 13 of 15 rooms out of a sample of 70 resident rooms. Specifically, the facility failed to ensure resident rooms had safe, comfortable temperatures that did not exceed 81 degrees Fahrenheit (F). Findings include: I. Facility policy and procedure The Indoor Climate Control policy, reviewed on 8/15/23, was provided by the nursing home administration (NHA) on 8/5/24 at 12:52 p.m. The policy revealed the following considerations were made to ensure that the facility remained cool during the late spring and summer months: The facility had four rooftop air conditioning (AC) units to cool the facility's corridors. […]