Columbine Commons Health and Rehab LLC

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Pharmacy Service Deficiencies

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.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

- Transfer Switch: Monthly test with generator 20 days to 40 days 110-2010; 8.4.6 and 99-2012; 6.4.4.1.1.4 - 8/2/24. .. Based on a record review, it was determined that the facility failed to maintain the fire alarm system components an.. Based on a record review, it was determined that the facility failed to maintain the fire alarm system components an.. Based on observation and staff interview during the course of the survey it was determined the facility failed to main.. Based on observation and staff interviews during the record review, it was determined that the facility failed to mai.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit sig.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the mea.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the mea.. Based on observation and staff interviews, it was determined that the facility failed to maintain fire barriers and fire.. Based on observation and staff interviews, it was determined that the facility failed to maintain fire barriers and fire.. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous ar.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as re.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as re.. Based on observations and a review, it was determined that the facility did not maintain fire extinguishers in accorda.. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In a.. Based on record review and staff interviews during the survey, it was determined that the facility failed to maintain .. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Li.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Li.. Based on the record review, it was determined that the facility failed to implement a smoking policy in accordance .. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteri.. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteri.. This STANDARD is not met as evidenced by: Through observation during the walkthrough of the survey it was determi.. Through observation during the documentation review, it was determined that the facility failed to meet the protect.. Through observation during the documentation review, it was determined that the facility failed to meet the protect..

A recertification survey with Incident #39728 was completed on 4/15/25 to 4/17/25. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 4/15/25 to 4/17/25. No deficiencies were cited. 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 referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/18/25. It revealed in pertinent part, "Time or temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less." (Chapter 3)B. Facility policy and procedureThe Kitchen Sanitation policy, revised 2023, was provided by the nursing home administrator (N.. 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 procedureThe 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. It read in pertinent part, "The resident has the right to be treated courteously, fairly and with the fullest measure of dignity, and to be cared for in a manner and environment that promotes maintenance or enhancement of his or her quality of life." II. Resident #8A. Resident statusResident #8, age greater than 65, was admitted 3/13/24. According to the April 2025 computerized physician order (CPO), diagnoses included atrial fibrillation (heart condition), chronic diastolic (congestive) heart fail..

Based on observation, it was determined that the facility failed to provide documentation that combustible decorations and fabrics were fire retardant and/or treated with a fire retardant spray. This was evidence by the following:A. Prohibited hanging of combustible decorations in Building 1 common area. NFPA 101, 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.110.3.1* Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.The Maintenance Director acknowledged the lack of documentation that the decorations were fire retardant. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on November 2, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."Building 1 is a one (1) story, Type V (111) construction. This facility was constructed in 2012. This LTC health care occupancy is separated from the attached assisted living occupancy by two-hour rated construction with 90-minute rated opening protection. The facility is licensed for 60 beds and the census for Building 1 on the date of this survey was 25. Building 2 is a (1) story, Type V (111) construction. This facility was constructed in 2020. This building is 26,500 sq. ft. and has an occupant load of 224.The facility is licensed for 60 beds and the census for building 1 was 26. Both buildings are protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system, and attic space and exterior canopy are protected by an anti-freeze loop. Both buildings are classified as fully sprinklered.The results of this survey were discussed with the Administrator and Maintenance Director during the exit conference.

A recertification survey was conducted from 10/9/23 to 10/12/23. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 10/9/23 to 10/12/23. No deficiencies were cited. 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 procedureThe Medication Receiving, Storage, and Destruction policy, revised September 2023, was provided by the nursing home administrator (NHA) on 10/11/23. 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, dispose.. 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 i.. Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#159) of three residents reviewed for hospice services out of 28 sample residents.Specifically, for Resident #159 the facility failed:-To have a hospice plan of care in order to maintain the resident' s highest practicable physical, mental and psychosocial well-being;-To identify the responsibilities of the hospice provider and the facility to include frequency of visits; and,-To have consistent documentation of hospice care visits and updates in the resident' s record.I. Facility po.. 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 August 2023, was provided by the director of clinical services (DCS) on 10/11/23 at 10:45 p.m. The policy documente..